HEALTH  SCIENCES  STANDARD 


HX00037206 


i^^^ 


m 


m 


m^- 


i^&^jssaa^s^si^-. 


.^< 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonorthopOOwhit 


A  TREATISE 


ORTHOPEDIC  SURGERY 


BY 

ROYAL  WHITMAN,  M.D.,  M.R.C.S.,  Eng.,  F.A.C.S. 

ASSISTANT    PROFESSOR    OF    ORTHOPEDIC    SURGERY    IN    THE     COLLEGE    OF     PHYSICIANS    AND 

SURGEONS    OF    COLUMBIA    UNIVERSITY,    NEW    YORK;    'PROFESSOR     OF     ORTHOPEDIC 

SURGERY    IN    THE    NEW   YORK    POLYCLINIC    MEDICAL    SCHOOL    AND    HOSPITAL; 

ASSOCIATE     SURGEON     TO     THE     HOSPITAL     FOR     RUPTURED     AND     CRIPPLED;      ORTHOPEDIC 

SURGEON    TO    THE    HOSPITAL    OF    ST.    JOHn'S    GUILD;      CONSULTING    ORTHOPEDIC 

SURGEON     TO     ST.    AGNES'    HOSPITAL    FOR     CRIPPLED     AND     ATYPICAL 

CHILDREN,   WHITE    PLAINS,   TO    THE    NEW  YORK    HOME    FOR 

DESTITUE  CRIPPLED  CHILDREN  AND  TO  THE  NEW 

YORK    STATE    BOARD    OF   HEALTH; 

MEMBER   OF   THE    AMERICAN   ORTHOPEDIC   ASSOCIATION;    CORRESPONDING   MEMBER    OF 

THE    BRITISH    ORTHOPEDIC    SOCIETY;   MEMBER    OF   THE    NEW    YORK   SURGICAL 

SOCIETY,    ETC. 


FIFTH  EDITION,  REVISED  AND  ENLARGED 


ILLUSTRATED  WITH  704  ENGRAVINGS 


LEA   &   FEBIGER 

PHILADELPHIA    AND   NEW   YORK 

1917 


Copyright 

LEA  &  FEBIGER 

1917 


TO 

VIRGIL  P.  GIBNEY,  M.D.,  LL.D. 

THIS  VOLUME  IS  INSCRIBED 

AS   A  TOKEN  OF  FRIENDSHIP  ASSURED   BY  LONG   ASSOCIATION 

AND   OF   APPRECIATION   OF   HIS   EFFORTS 

FOR   THE    ADVANCEMENT    OF 

ORTHOPEDIC    SURGERY 


PREFACE  TO  THE  FIFTH  EDITION. 


In  the  preparation  of  this  edition  it  has  been  the  purpose  of 
the  author  to  present  as  adequately  as  might  be  the  practice  of 
orthopedic  surgery  of  the  present  day. 

The  recent  epidemic  of  anterior  pohomyehtis  and  the  crippHng 
accidents  of  war  have  enforced  a  general  recognition  of  the  impor- 
tance of  orthopedic  principles  as  applied  both  for  prevention  and 
"^reconstruction." 

The  entire  book  has  been  carefully  revised  with  the  purpose  of 
presenting  the  broader  aspects  of  orthopedic  surgery  in  scope  and 
detail  as  defined  by  its  literature  and  by  the  work  of  representa- 
tive clinics  in  this  and  other  countries. 

The  causes  of  deformity  and  of  locomotor  disability  are  so  diverse 
and  unrelated  that  the  material  is  ill  adapted  to  conventional 
classification,  and  the  present  arrangement  has  been  selected  as  the 
most  practical  for  description  and  for  demonstration  to  students 
and  practitioners  of  medicine  for  whom  the  book  is  primarily 
designed. 

The  student  of  this  subject  is  especially  concerned  with  the 
mechanics  of  the  human  machine  with  its  development,  with  its 
capacity  at  different  periods  of  life  and  under  varying  condition, 
and  with  those  affections  that  lead  to  deformity  or  that  otherwise 
impair  its  usefulness.  He  is  concerned,  moreover,  not  only  with 
the  local  and  immediate  effects  of  disease  or  disability,  but  also 
with  its  general  influence  upon  the  entire  mechanism,  and  with  its 
ultimate  consequences  as  well. 

Orthopedic  surgery  occupies  a  broad  field  and  one  of  very  great 
and  general  interest.  Its  most  distinctive  advance  in  recent  years 
has  been  toward  the  prevention  of  deformity,  an  advance  that  has 
been  made  possible  by  the  better  understanding  of  its  predisposing 
and  exciting  causes.  As  a  natural  consequence,  treatment  has 
become  more  direct,  more  simple,  and  more  effective.  It  has  been 
the  purpose  of  the  author  to  emphasize  this  aspect  of  the  subject. 


vi  PREFACE 

which  is  of  the  greatest  importance  to  the  general  practitioner, 
who  so  often  has  the  opportunity  to  recognize  disease  or  disability 
in  its  incipiency,  when  its  progress  may  be  checked  by  timely 
treatment. 

The  author  has  endeavored  to  present  orthopedic  sm-gery,  as  far 
as  possible,  objectively,  and  in  a  manner  that  has  proved  acceptable 
to  students  and  practitioners  in  clinical  teaching.  Thus  the  selection 
of  each  subject  and  the  space  that  has  been  allotted  to  it  has  been 
determined  primarily  by  its  relative  importance  in  the  actual  work 
of  orthopedic  clinics.  He  has  been  at  some  pains,  also,  to  outline 
methods  of  examination,  to  explain  the  phenomena  of  the  sjTup- 
toms,  and  so  to  describe  and  to  illustrate  the  causes  and  effects  of 
disease  and  disability  as  to  indicate,  in  natural  sequence,  the  prin- 
ciples of  treatment;  but  the  particular  methods  of  the  application 
of  these  principles,  which  have  been  described  in  detail  are  always 
those  that  have  been  tested  by  personal  experience. 

Although  this  book  is  designed  particularly  for  students  and 
practitioners  of  medicine,  the  author  has  included  statistical  and 
other  data  which  he  hopes  may  prove  of  interest  to  his  fellow- 
workers  in  this  special  field. 

R.  W. 

New  York,  1917. 


CONTENTS. 


CHAPTER   I. 

Tuberculous  Disease  of  the  Spine. 

Description  —  Pathology  —Etiology — Statistics — General  prognosis 
— Symptoms — Physical  examination — Contour  and  flexibility  of 
the  spine — Divisions  of  the  spine — Landmarks — The  differential 
diagnosis  of  disease  in  the  lower,  middle,  and  upper  regions  of  the 
spine — Treatment  by  horizontal  fixation — by  convex  stretcher 
frame — ^by  plaster  jackets — by  Calot  jacket — by  braces  —  by 
other  means.  The  selection  and  adaptation  of  treatment  for  dis- 
ease of  the  different  regions  of  the  spine.  The  comphcations  of 
tuberculous  disease  of  the  spine — ^Abscess — course — symptoms — ■ 
treatment.  Paralysis — course — symptoms — treatment.  Recur- 
rence of  disease — Secondary  deformities 17-118 


CHAPTER  II. 

Non-tuberculous  Affections  of  the  Spine. 

Syphilis — -Malignant  disease  —  Osteomyelitis,  acute  and  chronic — 
Actinomycosis — Injury — Traumatic  spondylitis — -Typhoid  spine 
—  Gonorrheal  arthritis  of  the  spine  —  Arthritis  —  Spondylitis 
deformans,  varieties — Kyphosis  of  adolescents — Rhachitic  spine 
— Osteitis  deformans — Tabetic  deformity — Spondylolisthesis — 
Pain  in  the  back — Sciatic  scoliosis — Disease  and  injury  at  the 
sacro-ihac  articulation — Coccygodynia 119-143 


CHAPTER  III. 

Lateral  Curvature  of  the  Spine. 

Description — habitual  and  fixed  deformity,  rotation  and  lateral- 
deviation.  Pathology — Etiology  —  Statistics  — Varieties  —  Dis- 
tribution and  effects  of  deformity  —  Symptoms — Diagnosis  — 
Prognosis — Prevention  of  deformity — Desks,  chairs — Principles 
of  treatment — Treatment — by  posture  and  exercises — general 
exercises — heavy  exercises — special  exercises — Supports.  Forc- 
ible correction  of  deformity — Adjuncts  in  treatment — The  Abbott 
treatment — Supplemental  treatment — Duration  of  treatment     .      144-227 


Vlll  CONTEXTS 

CHAPTER    IV. 

Deformities  of  the  Spixe  (Coxtintjed).     Deformities  of  the 
Chest.     The  Ftjxctioxal  Pathogexesis  of  Deformity. 

Variation  in  contour  of  the  spine — The  round  and  the  fiat  back — 
KjTihosis  —  Lordosis  —  Congenital  elevation  of  the  scapula  — 
Absence  of  vertebrae — Abnormalities  of  ribs — Cervical  ribs — 
Absence  of  ribs  —  ^Malformation  of  pectoral  muscle  —  Abnor- 
mality of  clavicle — Flat  chest — Pigeon  chest — Funnel  chest — 
]Minor  Deformities — Scapular  Crepitus — ^Acquired  luxation  or 
subluxation  of  the  clavicle — Asymmetrical  development — Tables 
of  height,  weight,  and  circumference  of  the  chest — Functional 
pathogenesis  of  deformity — (Wolff's  law) — Atrophy  of  bone — 
Hypertrophy  of  bone 228-248 

CHAPTER   V. 
TUBERCUI.OUS  Disease  of  the  Boxes  axd  Joixts. 

Predisposition — Mode  of  infection — Latent  tuberculosis — Local  pre- 
disposition— Statistics — distribution  of  disease — location — side 
affected — sex — age.  Pathologj' — Varieties  of  disease — synovial 
— arborescent  syno\dal  form — rice  bodies — caries  sicca — Tuber- 
culous rheumatism — Septic  infection — Progress  and  method  of 
repair — Prognosis — Diagnosis — Treatment  —  direct  sunlight  — 
operative  and  mechanical — by  drugs — local  apphcations — Iodo- 
form filling  —  Cabot's  fluids  —  Beck's  preparation  —  X-ray  — 
Active  and  passive  congestion — venous  stasis  (Bier's  treatment)      249-269 

CHAPTER  VI. 
Xox-TrBERCULOirs  Dise.\ses  of  the  Joixts. 

Sj'phihtic  disease  of  joints — Gonorrheal  arthritis — Other  forms  of 
infectious  arthritis — Acute  osteomyehtis — Subacute  osteomye- 
litis —  Arthritis  deformans  —  Osteo-arthritis  and  rheumatoid 
arthritis — Varieties — Treatment — Still's  disease — Gout — Rheu- 
matism — Hemophiha  —  Hemarthrosis  —  Scorbutus  —  Charcot's 
disease — Other  forms  of  arthropathy — Anchylosis — Treatment — 
iSIalignant  disease  of  bone 270-304 

CHAPTER   VII. 
Tuberculous  Disease  of  the  Hip-joixt. 

Pathology — Etiology — Statistics — S^^mptoms — Physical  signs,  stiff- 
ness, distortion,  apparent  lengthening,  apparent  shortening — 
Changes  in  contour — Atrophj^ — Causes  of  actual  shortening — 
^Measurements — Lovett's  table — Kingsley's  table — Explanation 
of  phj'sical  signs — Differential  diagnosis — Principles  of  treatment 
— The  traction  hip  brace — Traction  plasters — The  Thomas  brace 
— The  plaster  bandage — Various  methods  of  reducing  deformity 
— Comparison  of  methods  of  treatment — The  long  hip  splint — 
The  hip  splint  and  the  plaster  spica — Other  forms  of  apparatus 
— Bilateral  hip  disease — Hip  disease  in  infancy — Hip  disease  in 
adult  life — Abscess — statistics — sinuses — treatment — Operative 
treatment — exploration — excision — Amputation — reduction  of 
resistant  deformity' — Prognosis,  mortality,  functional  results — 
Secondarj'  deformities  of  liip  disease — Treatment — Final  results     305-398 


CONTENTS  IX 

CHAPTER  VIII. 

Non-tuberculous  Affections  of  the  Hip-joint. 

Statistics — Traumatisms  at  the  hip — Acute  infectious  arthritis — 
Acute  epiphysitis — Subacute  arthritis — Gonorrheal  arthritis — 
Spontaneous  dislocation — Extra-articular  disease — Bursitis — 
Malignant  disease  at  the  hip-joinu — Cysts  of  the  femur — Osteitis 
fibrosa  —  Arthritis      deformans  —  Osteochondritis      deformans 

•       juvenilis 399-409 

CHAPTER  IX. 

Tuberculous  Disease  of  the  Knee-joint. 

Pathology — Etiology — Statistics — Symptoms,  primary  and  secondary 
distortions — Shortening  and  lengthening — Diagnosis — Differen- 
tial diagnosis — Treatment — Reduction  of  deformity — Forms  of 
braces  —  Accessories  in  treatment  —  Extra-articular  disease — • 
Abscess — Synovial  tuberculosis — Operative  treatment — arthrec- 
tomy — excision,  amputation — Prognosis — mortality — functional 
results — General  conclusions 410-436 

CHAPTER  X. 

Non-tuberculous  Affections  and  Deformities  of  the  Knee-joint. 

Injury  in  childhood — Acute  synovitis — Chronic  and  recurrent  syno- 
vitis— Incidental  synovitis — "Quiet  effusion" — Internal  derange- 
ment of  knee-joint — Loose  bodies  in  knee-joint — Displacement 
of  semilunar  cartilage — Osteochondritis  dessicans — Osteochon- 
dromatosis— Hyperplasia — Prepatellar  bursitis — Pretibial  bursi- 
tis— Enlargement  of  superficial  pretibial  bursa — Injury  of  tibial 
tubercle — Bursse  and  cysts  in  the  popliteal  region — Acquired 
genu  recurvatum — Congenital  genu  recurvatum — Rudimentary 
or  absent  patella — Congenital  and  acquired  displacement  of 
patella — Slipping  patella — Elongation  of  the  hgamentum  patellae 
— Snapping  knee — Congenital  contraction  at  the  knee — General 
contractions 437-454 

CHAPTER   XL 

Diseases  and  Injuries  of  the  Ankle-  and  Tarsal  Joints.    ■ 

Tuberculous  disease — Pathology — Etiology — Statistics — Symptoms 
—  Diagnosis — Treatment  —  Prognosis — Tuberculous  disease  of 
the  tarsus — Statistics — Treatment — Kohler's  disease — Sprain  of 
the  ankle — Chronic  sprain — Fracture  of  tarsal  bones — Teno- 
synovitis —  Tuberculous  tenosynovitis  —  Swelling  about  the 
ankles 455-472 

CHAPTER   XII. 

Diseases  and  Injuries  of  the  Articulations  of  the  Upper 
Extremity. 

Tuberculous  disease  of  the  shoulder- joint — Pathology — Statistics — 
Symptoms — Treatment — Prognosis — Tuberculous  disease  of  the 
elbow-joint  —  Pathology  —  Statistics  —  Symptoms  — Treatment 


X  cox  TEXTS 

— Prognosis — Tuberculous  disease  of  the  wrist-joint — Symptoms 
— Treatment  —  Prognosis  —  Spina  ventosa  — •  Periarthritis  of 
the  shoulder — Chronic  bursitis  at  the  shoulder — Sprain  of  the 
wi'ist — Acute  and  chronic  tenosj'novitis  at  the  wrist    ....     473-488 

CHAPTER  XIII. 

Deformities  of  the  Upper  Extremity. 

Congenital  dislocation  of  the  shoulder — Obstetrical  paralysis  and  dis- 
location— Treatment — Operation  on  brachial  plexus — Recurrent 
dislocation  of  the  shoulder — Congenital  deformities  of  the  elbow 
—  Congenital  pronation  of  the  forearm  — •  Cubitus  valgus  — 
Cubitus  varus — Subluxation  of  the  -RTist — Congenital  deform- 
ities at  the  wrist — Club-hand — Varieties — Treatment — Club- 
hand associated  with  defective  development — Contractions  and 
distortions  of  the  fingers — Webbed  fingers — Congenital  displace- 
ment of  phalanges — Trigger-finger  —  Mallet-finger  —  BasebaU- 
finger — Dupuytren's  contraction — Ischemic  paralysis  and  con- 
traction       489-508 

CHAPTER   XIV. 
Coxgexital  axd  Acquired  Affectioxs  Leadixg  to  Gexeral 

DiSTORTIOXS. 

Rliacliitis  — Etiology  — Pathology —  S^^nptoms,  deformities  — Prog- 
nosis— Treatment — "Late  rickets" — Infantile  scorbutu.s — Chon- 
droch'strophia  — Dyschondroplasia  —  Osteitis  fibrosa  — ^Multiple 
myeloma  —  Fragihtas  ossium  —  Osteomalacia  —  Osteitis  defor- 
mans— Secondarj'  hj'pertrophic  osteo-arthropathj' — ^AcromegaUa     509-528 

CHAPTER   XV. 
Coxgexital  Dislocatiox  of  the  Hip  axd  Coxa  V.ara. 

Congenital  dislocation  of  the  hip-joint  —  Statistics  —  Pathology'  — 
Etiologj' — Symptoms,  unilateral,  bilateral,  anterior  dislocations, 
Supracotyloid  displacement — Diagnosis — Differential  diagnosis 
— Treatment — the  Lorenz  operation — Details  and  modifications 
— Treatment  in  infancy — Prognosis — Treatment  of  older  subjects 
— Arthrotomj- — Osteotomy — Open  operation  of  Hoffa-Lorenz — 
Re^dew  of  treatment — PaUiative  treatment — Congenital  sub- 
luxation of  the  hip — Snapping  hip — Coxa  vara — Pathologj" — 
Etiolog}' — Statistics — S\TQptoms,  unilateral,  bilateral — Diag- 
nosis —  Treatment  —  mechanical  —  operative  —  Forcible  abduc- 
tion— Osteotomy — Linear — Cuneiform — Fracture  of  the  neck  of 
the  femur — Traumatic  coxa  vara — Simple  fracture — Epiphj'seal 
fractm-e — Fracture  in  adult  life — The  author's  treatment  for 
complete — for  impacted — Coxa  valga 529-582 

CHAPTER  XVI. 
Deformities  of  the  Bones  or  the  Lower  Extremity. 

Bow-leg  —  ICnock-knee  —  Statistics  —  Etiology  —  The  outgrowth  of 
deformit J' —  Genu  valgum  — Description  — Attitudes  —  Second- 
ary deformities  —  Gait  —  Unilateral  deformity  —  Patholog\-  — 
Treatment — expectant — mechanical — operative — Genu  varum — 
SjTnptoms — Treatment — expectant — mechanical — operative — • 
Anterior  bow-leg — General  rhachitic  distortions 583-609 


CONTENTS  xi 

CHAPTER  XVII. 

Diseases  of  the  Nervous  System. 

Acute  anterior  poliomyelitis  —  Pathology  —  Etiology — Statistics  — 
Symptoms  —  Diagnosis  —  Differential  diagnosis  —  Prognosis  — 
Causes  of  Deformity — Deformity  in  various  regions— Subluxa- 
tion— Retardation  of  growth— Principles  of  Treatment — Treat- 
•  ment,  mechanical,  operative — Tendon  and  muscle  transplanta- 
tion— Arthrodesis— Nerve  grafting — Recapitulation    ....     610-640 

CHAPTER  XVIII. 

Diseases  of  the  Nervous  System  (Continued). 

Cerebral  paralysis  of  childhood  —  Description  —  Distribution  — 
Etiology  —  Pathology  —  Symptoms  —  Congenital  weakness  and 
paralysis  —  Acquired  paralysis  —  Hemiplegia  —  Paraplegia — 
Treatment,  mechanical,  operative  —  Prognosis  —  Spastic  spinal 
paraplegia— Progressive  muscular  atrophy — Varieties— Heredi- 
tary ataxia— Neuritis— Hysterical  and  functional  affections  of 
the  joints  —  Neurotic  spine  —  Hysterical  spine  —  "Hysterical 
scoHosis  "  —  "  Hysterical  hip ' '  —  Hysterical  talipes  —  Neurotic 
joints 641-659 

CHAPTER  XIX. 

Congenital  and  Acquired  Torticollis. 

Description- Statistics  —  Congenital  torticollis— Etiology— Hema- 
toma of  the  sternomastoid  muscle — Acquired  torticollis — Varie- 
ties— Acute  torticolhs  —  Etiology  —  Symptoms  —  Diagnosis  — 
Treatment  of  chronic  torticolhs — mechanical,  operative— Treat- 
ment of  acute  torticolhs  —  Spasmodic  torticollis  —  Etiology  — 
Pathology — Treatment — Exceptional  forms  of  torticolhs— para- 
lytic—  diphtheritic  —  cervical  opisthotonos  —  rhachitic  —  ocular 
—psychical 660-679 


CHAPTER  XX. 

Disabilities  and  Deformities  of  the  Foot. 

General  description  of  the  foot  and  of  its  functions— The  arches,  the 
foot  as  a  passive  support,  in  activity,  improper  postures,  move- 
ments—Function of  the  muscles— Strength  of  the  muscles— The 
foot  as  a  mechanism— The  weak  foot  or  so-called  flat-foot- 
Description  —  Anatomy  —  Etiology  —  Statistics  —  Pathology  — 
Symptoms— Diagnosis— Varieties— Weak  foot  in  childhood  — 
Exceptional  forms  —  Treatment  —  Preventive  —  Exercises  — 
Support— Construction  of  brace— The  rigid  weak  foot— Forcible 
correction  of  deformity— Functional  use  in  the  overcorrected 
attitude— Systematic  manipulation — Subsequent  treatment — 
Adjuncts  in  treatment — Operative  treatment 680-727 


Xll  CONTENTS 

CHAPTER  XXI. 

Disabilities  and  Deformities  of  the  Foot  (Continued). 

The  hollow  or  contracted  foot — ^Varieties  and  treatment — Anterior 
metatarsalgia  —  Morton's  neuralgia  —  Etiology  — Treatment  — 
Painful  warts — Achillobursitis — Strain  of  the  tendo-Achilles — 
Calcaneobursitis — Plantar  neuralgia — Vasomotor  trophic  neu- 
roses—  Angioneurotic  edema,  acroparesthesia,  erythromelalgia, 
RajTiaud's  .  disease  —  Dj^sbasia  angiosclerotica  (Intermittent 
limp)  —  Thrombo-angiitis  obliterans  —  Hallux  rigidus  (Painful 
great  toe) — Hallux  varus  —  Pigeon-toe — Metatarsus  varus  — 
Hallux  valgus — Bunion — Hammer-toe — Ingrown  toe-nail — Over- 
lapping toes — Exostoses  of  the  foot — Fracture  of  metatarsus — 
Supernumerary  bones — Displacement  of  the  peronei  tendons — • 
Shoes,  effects  of  improper  shoes — Demonstration  of  the  proper 
shoe— Socks 728-762 


CHAPTER  XXII. 

Deformities  of  the  Foot. 

Talipes  —  Description — Varieties  —  Statistics  of  tahpes,  congenital 
and  acquired — Relative  frequency  of  the  different  varieties — 
Congenital  talipes — Etiology — Anatomy — Symptoms  —  Treat- 
ment— Principles  of  treatment  of  infantile  club-foot — mechanical 
— by  plaster  bandage — by  braces — restoration  of  function — 
supervision — Treatment  in  older  subjects — forcible  manual  cor- 
rection— malleotomy — tenotomy — Wolff's  treatment,  reduction 
of  deformit}^  by  wrenches — Phelps'  operation — Operations  on  the 
bones — Astragalectomy — Osteotomj^ — Mechanical  treatment — 
Other  varieties  of  congenital  tahpes — varus — equinus — cal- 
caneus —  valgus  —  equinovalgus  —  calcaneovalgus  — •  calcaneo- 
varus  —  equinocavus  —  valgocavus  —  Congenital  deformities  of 
foot  associated  with  defective  development — with  absence  of 
fibula — wdth  absence  of  tibia — with  congenital  deficiency  and 
hypertrophy — Constricting  bands — Congenital  h^iDertrophy — 
Spina  bifida  and  talipes 763-819 

CHAPTER  XXIII. 

Deformities  of  the  Foot  (Continued). 

Acquired  tahpes — Etiology — Diagnosis — Talipes  equinus — Etiology 
• — •  Symptoms  —  Treatment  —  mechanical  —  operative  —  Tahpes 
equinovarus — Treatment — Tahpes  equinovalgus — Simple  tahpes 
valgus  —  Tahpes  calcaneus  —  Description  —  Development  of 
deformity  —  SjTnptoms  — Treatment  —  mechanical,  operative — 
WiUett's  operation — The  author's  operation — Tahpes  calcaneo- 
valgus and  calcaneovarus  —  Tendon  transplantation  in  the 
treatment  of  paralj'tic  tahpes  —  Tendon  transplantation  and 
arthrodesis 820-858 


CHAPTER  XXIV. 
Military  Orthopedics 859-870 


ORTHOPEDIC  SURGERY. 


CHAPTER  I. 
TUBERCULOUS  DISEASE  OF  THE  SPINE. 

Synonym. — Pott's  disease. 

Pott's  disease  is  a  chronic  destructive  process  of  the  bodies 
of  the  vertebrfe.  The  spine  bends  at  the  weakened  point,  and 
the  upper  part,  sinking  downward  and  forward,  throws  into 
relief  one  or  more  of  the  spinous  processes,  thus  an  angular 
posterior  projection  is  formed.  It  is  called  Pott's  disease  be- 
cause such  deformity,  accompanied  by  pain  and  oftentimes  by 
paralysis,  was  first  described  in  English  by  Percival  Pott  in 
1779.  Angular  deformity  is  simply  the  evidence  of  local  weak- 
ness. Thus  it  might  be  the  result  of  fracture,  or  of  the  erosion 
of  an  aneurism,  or  of  malignant  disease,  or  syphilis,  or  other 
pathological  process;  but  deformity  from  such  causes  is  not  now 
included  under  Pott's  disease,  nor  is  the  term  now  synonymous 
with  deformity.  In  the  modern  sense  it  signifies  tuberculous 
disease  of  the  bodies  of  the  vertebrae,  of  which  the  early  symp- 
toms may  be  detected  and  of  which  the  deforming  effects  may 
be  checked  and  even  prevented  by  timely  treatment. 

The  disintegration  and  collapse  of  the  affected  parts  cause  the 
characteristic  angular  projection  at  the  seat  of  the  disease  (Fig. 
2).  If  one  vertebral  body  is  destroyed  the  projection  will  be 
sharp;  if  several  are  implicated  it  will  be  less  angular,  and  if 
one  side  of  a  body  breaks  down  before  the  other  there  may  be 
lateral  as  well  as  posterior  distortion. 

The  degree  of  the  deformity  and  its  effects  are  determined  pri- 
marily by  its  situation.  If  the  disease  is  at  either  extremity  of  the 
spine  the  angular  projection  is  slight  because  the  area  of  the  spine 
directly  involved  in  the  deformity  is  small  compared  to  that  which 
is  free  from  disease  (Fig.  5) .  But  if  the  centre  of  the  spine  is  affected 
the  opportunity  for  deformity  is  great,  because  the  entire  column 
may  enter  into  the  formation  of  the  angular  kj^hosis.  In  such 
cases  the  capacity  of  the  chest  is  lessened  and  the  internal  organs 
are  compressed  (Fig.  23). 
2 


18 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


y^:^ 


Pott's  disease,  as  contrasted  with  tuberculosis  of  other  bones 
and  joints,  is  pecuhar  in  its  inaccessibility;  in  its  proximity  to 
important  parts,  the  vital  organs  in  front 
and  the  spinal  cord  behind.  Finally,  in 
that  the  effects  of  disease  and  deformity 
influence  in  much  greater  degree  the  entire 
mechanism  of  the  body. 

Pathology. — ^The  minute  changes  that 
characterize  tuberculosis  of  bone  in  general 
are  described  in  Chapter  V. 

The  first  indication  of  the  disease  is 
usually  found  in  the  anterior  part  of  a  ver- 
tebral body  just  beneath  the  fibroperi- 
osteal  layer  of  the  anterior  longitudinal 
ligament.  From  this  point  the  granula- 
tion tissue  advances  along  the  front  of  the 
spine,  and  following  the  course  of  the 
bloodvessels  it  invades  the  underlying 
bone.  In  other  instances  the  process  may 
begin  in  the  interior  of  a  vertebral  body, 
most  often  in  several  minute  foci  near 
the  upper  or  lower  epiphysis.  These  coal- 
escing, gradually  enlarge,  forming  a  cavity, 
enclosed  by  cortical  substance,  which  finally 
collapses  under  the  pressure  of  the  super- 
incumbent weight.  Occasionally  the  dis- 
ease advances  beneath  the  anterior  liga- 
ment without  implicating  deeply  the 
substance  of  the  bone — a  form  of  tuber- 
culous periostitis,  "spondylitis  super- 
ficialis." 
The  intervertebral  disks  appear  to  offer  some  resistance  to 
the  extension  of  the  disease  from  one  vertebra  to  another,  but 
when  the  bone  is  destroyed  on  either  side  they  quickly  disin- 
tegrate and  disappear.  The  posterior  part  of  the  spinal  column 
usually  remains  free  from  disease,  with  the  exception  of  the 
pedicles  and  articulations  that  may  be  in  direct  contact  with  it. 
In  rare  instances  the  process  may  begin  in  a  lamina  or  spinous 
process,  or  in  one  of  the  small  joints;  but  such  forms  of  local 
tuberculosis  could  hardly  be  classed  as  Pott's  disease. 

The  course  and  outcome  of  the  disease  depend  upon  its  type. 
In  one  instance  the  area  of  primary  infection  is  small  and  the 
local  resistance  is  sufficient  to  check  its  further  progress,  so  that 
cure  without  deformity  may  follow.  In  another  the  disease  is 
inactive  and  the  granulation  tissue  undergoes  a  fibroid  trans- 
formation or  becomes  ossified.  In  such  cases  deformity  may 
appear  and  slowly  increase,   practically  without   symptoms.     In 


Fig.  1. — Destruction  of 
the  bodies  of  the  first,  sec- 
ond and  third  lumbar  ver- 
tebrae— with  the  resulting 
deformity.      (Menard.) 


PATHOLOGY 


19 


most  instances,  however,  the  infected  granulations  advance  more 
rapidly,  destroying  the  bone  or  other  tissue  with  which  they 
come  into  contact.  There  is  the  usual  retrograde  metamorphosis 
to  cheesy  degeneration,  and  very  frequently  liquefaction  and 
abscess  formation  follow. 


Fig.  2. — -Pott's  disease. 


In  cases  of  moderate  severity  that  come  to  autopsy  during  the 
progressive  stage  of  the  disease,  one  finds,  usually,  on  dividing  the 
thickened  tissues  in  front  of  the  spine,  a  cavity  the  walls  of  which 
are  lined  with  granulation  tissue  in  various  stages  of  degeneration, 
and  containing  puriform  fluid.  The  adjoining  vertebral  bodies 
present  a  worm-eaten  appearance,  and  one  or  more  of  them  is 
partially    destroyed.     Small    fragments    of  necrosed  bone,  "bone 


20  TUBERCULOUS  DISEASE  OF   THE  SPINE 

sand,"   may  be   recognized,   and   occasionally  sequestra   of    con- 
siderable size  are  present. 

If  the  disease  begins  in  the  interior  of  a  vertebral  body  it  may 
extend  backward  as  well  as  forward,  and  forcing  its  way  into 
the  vertebral  canal  it  may  involve  the  coverings  of  the  spinal 
cord  and  cause  pressure  paralysis  even  before  the  deformity 
attracts  attention.  Less  often  pressure  on  the  cord  may  be  due 
to  the  presence  of  an  abscess  or  to  displacement  of  bone.  The 
calibre  of  the  spinal  canal  may  be  constricted  somewhat  by  press- 
ure incidental  to  progressive  deformity  upon  the  softened  and 
thickened  tissues  at  the  seat  of  disease,  but  as  a  rule  its  capacity 
is  not  directly  lessened  by  the  angular  distortion,  nor  does  the 
degree  of  deformity  directly  influence  the  frequency  of  par- 
alysis. 

Although  the  disease  may  begin  in  multiple  primary  foci  through- 
out an  extended  area,  or  in  two  or  more  distinct  regions  of  the 
spine  simultaneously,  yet  clinical  observation  indicates  that  it  is, 
in  most  instances,  originally  confined  to  one  or  two  adjacent  bodies. 
From  this  central  point  it  may  extend  indefinitely  in  either  direc- 
tion, but  in  ordinary  cases  the  final  area  of  deformity  and  rigidity 
shows  that  from  three  to  six  bodies  are  more  or  less  involved  before 
cure  is  established. 

If  the  disease  is  limited  in  extent,  the  eroded  surfaces  of  the 
adjoining  vertebrfe  may  come  into  direct  contact;  but  if  several 
vertebral  bodies  have  been  destroyed,  the  upper  portion  of  the 
spine  as  it  sinks  downward  is  often  displaced  backward,  so  that 
the  anterior  part  of  one  or  more  of  the  upper  segments  may 
be  apposed  to  the  superior  surface  of  the  first  body  of  the  lower 
section  (Fig.  3).  Less  often  there  may  be  forward  displace- 
ment of  the  upper  part  upon  the  lower  (Fig.  1 ) . 

At  all  stages  of  the  disease  resistance  to  its  progress  is  evident 
in  the  affected  parts. 

Repair  is  accomplished  occasionally  by  contact  and  solid 
union  of  the  adjoining  surfaces  of  softened  bone;  but  usually 
the  anchylosis  is  in  part  fibrous,  in  part  cartilaginous,  and  in 
part  bony,  and  this  union  may  be  fm-ther  strengthened  by  a 
callus  formation  from  the  thickened  tissues  about  the  seat  of 
the  disease.  In  cases  of  long  standing  the  articular  processes,  the 
pedicles,  and  laminae  may  become  anchylosed  before  repair  has  ad- 
vanced appreciably  in  the  anterior  portion  of  the  column. 

Cure  may  be  absolute,  as  when  no  vestige  of  the  disease 
remains;  it  may  be  practically  assm-ed,  as  when  the  diseased 
products  undergo  calcareous  degeneration  and  are  shut  in  by 
a  layer  of  solid  bone.  In  other  instances  the  disease  becomes 
quiescent  or  but  slowly  advances,  showing  its  presence  by  ex- 
acerbations of  pain  or  by  the  formation  of  an  abscess  long  after 
active  symptoms  have  ceased. 


RELATIVE  FREQUENCY 


21 


Etiology. — The  etiology  of  tuberculosis  of  the  spine  does  not 
differ  from  that  of  tuberculosis  of  other  bones;  the  subject  is 
considered  in  Chapter  V. 


D 

L ^::?^^"'T  '-.-..-^./^,,-;^..s 

\ 

Fig.  3. — -Destruction  of  the  bodies  of  ^ 

the  third,  fourth,  fifth,  sixth  and  seventh  Fig.  4. — The     deformity     corrected, 

dorsal  vertebrse;  partial  destruction  of  showing    the    area    of    the    destructive 

three  others.     (Menard.)  process.      (Menard.) 

Relative  Frequency. — ^Tuberculosis  of  the  spinal  column  is 
more  common  than  of  any  other  single  bone  or  joint,  as  might 
be  expected  from  its  greater  area.  This  is  illustrated  by  the 
statistics  of  tuberculous  disease  treated  in  the  out-patient  depart- 
ment of  the  Hospital  for  Ruptured  and  Crippled  during  a  period 
of  twenty  years,.  1885-1904. 

Cases. 

Tuberculosis  of  the  spine 4299 

Tuberculosis  of  the  hip 3329 

Tuberculosis  of  other  joints  inclusive 3222 

Total 10,850 


22  TUBERCULOUS  DISEASE  OF   THE  SPINE 

Also  by  statistics  of  the  Boston  Children's  Hospital  for  a  similar 
period,  1869-1888: 

Cases. 

Tuberculosis  of  the  spine 1864 

Tuberculosis  of  the  hip,  knee,   ankle,  shoulder,   elbow,   and  wrist 

combined 1856 

Total 3720 

Of  1996  autopsies  on  subjects  with  tuberculous  disease  of  bones 
and  joints  the  spine  was  involved  in  702 — 35.2  per  cent.^ 

Age. — Pott's  disease,  although  far  more  frequent  in  the  middle 
period  of  childhood,  from  the  third  to  the  tenth  year,  may  appear 
in  earliest  infancy  or  extreme  age. 

In  a  series  of  1259  consecutive  cases  of  tuberculosis  of  the 
spine  collected  from  the  records  of  the  outdoor  department  of 
the  Hospital  for  Ruptured  and  Crippled,  analyzed  by  Drs. 
R.  T.  Frank  and  C.  Gunter,  the  ages  of  the  patients  at  the  sup- 
posed time  of  onset  of  the  disease  appeared  to  be  as  follows: 

Per  cent. 

Less  than  1  year 38  =    3 . 1 

Between     1  and    2  years 176  =  14 . 2 

Between    3  and    5  years 627  =50.2 

Between    6  and  10  years    .      .       .      .    " 234  =  18.3 

Between  11  and  20  years 89   =     7.2 

Between  21  and  30  years 43=3.5 

Between  31  and  50  years 31    =     2.6 

Over  50  years 11=0.8 

The  youngest  patient  was  two  months  old,  the  oldest  seventy- 
one  years. 

Thorndike,-  from  the  records  of  the  Boston  Children's  Hos- 
pital for  thirteen  years,  1883  to  1896,  collected  115  cases  of 
tuberculosis  of  the  spine  in  children  of  two  years  or  less.  Seven 
of  these  were  l&ss  than  six  months,  and  20  were  under  one  year 
of  age. 

Howard  INIarsh^  has  called  attention  to  Pott's  disease  in  the 
aged,  and  cites  3  cases  in  subjects  of  sixty  or  more  years  of 
age. 

Sex. — Sex  exercises  comparatively  little  influence  on  the  lia- 
bility to  disease  of  this  region.  Of  6931  cases  tabulated  by  Wull- 
stein'*  3704  were  in  males  (53.29  per  cent.).  Of  1367  cases  collected 
by  Frank  and  Gunter,  708  (52  per  cent.)  were  in  males  and  659  (48 
per  cent.)  were  in  females;  and  in  2455  cases  tabulated  by  Knight, 
1329  were  in  males  and  1126  in  females.  Of  these  combined  cases 
from  the  Hospital  for  Ruptured  and  Crippled,  3822  in  number, 
53.2  per  cent,  were  in  males  and  46.8  per  cent,  in  females. 

1  Billroth-Menzel:  Handb.  der  orthop.  Chir.,  Joachimsthal,  S.  1304. 
=  Tr.   Am.   Orthop.   Assn.,    1896,   ix.  ^  ibjd.,  1891,  iv. 

*  Ztschr.  f.  orthop.  Chir.,  October,  1912. 


THE  SITUATION  OF   THE  DISEASE 


23 


iThe  Situation  of  the  Disease. — The  dorsolumbar  section  of 
the  spine  is  most  often  affected.  Cervical  disease  is  compara- 
tively infrequent. 

In  the  series  of  1355  cases  from  the  records  of  the  Hospital 
for  Ruptured  and  Crippled,  the  attempt  was  made  to  locate  the 
origin  of  the  disease  by  the  most  prominent  spinous  process  in 
the  tracing.     The  following  are  the  conclusions : 


Cervical. 

Dorsal. 

Lumbar. 

Lumbosacral 

First       ....          3 

26 

94 

13 

Second  . 

3 

43 

96 

Third     . 

15 

42 

64 

Fourth^  . 

20 

46 

57 

Fifth       . 

13 

-    49 

6 

Sixth      . 

22 

■       76 

Seventh 

24 

82 

Eighth   . 

97 

Ninth     . 

92 

Tenth     . 

110 

Eleventh 

71 

Twelfth 

120 

100 


854 


317 


13 


No  deformity,  cervical ' 2w 

No  deformity,  dorsal 31 

55 

No  deformity,  lumbar 22 

Disease  in  two  regions  of  the  spine 16 

Similar  statistics  are  recorded  by  Dollinger/  of  Budapest, 
of  700  cases  of  Pott's  disease.  Of  these  the  situation  of  the  pri- 
mary disease  could  be  ascertained  in  538.  In  63  the  disease 
was  of  the  cervical,  in  321  of  the  dorsal,  and  in  154  of  the 
lumbar  region.  Of  700  cases  reported  by  Hayashi  and  Matsuoka, 
of  Japan,  the  thoracic  vertebrae  were  involved  in  53.43  per  cent., 
the  lumbar  in  41 .29  per  cent.,  and  the  cervical  in  5.28  per  cent.^ 

The  relative  frequency  of  disease  of  the  different  dorsal  and 
lumbar  vertebrae  was  as  follows: 


First  . 
Second  . 
Third  . 
Fourth  . 
Fifth  . 
Sixth  . 
Seventh 
Eighth  . 
Ninth  . 
Tenth  . 
Eleventh 
Twelfth 


orsal. 

Lumbar. 

6 

59 

7 

37 

12 

31 

10 

17 

19 

10 

17 

33 

36 

36 

43 

38 

64 

321 


154 


1  Die  Behandlung  der  Tuberculosen  Wirbelentzundung,  Stuttgart,  1898. 

2  Ztschr.  f.  orthop.  Chir.,  xxxiv,  381. 


24  TUBERCULOUS  DISEASE  OF   THE  SPINE 

Of  517  cases  treated  at  the  New  York  Orthopedic  Hospital  the 
location  was  as  follows:^ 

Cer\dcal 47 

Upper  dorsal 71 

Mid-dorsal 118 

Lower  dorsal 105 

Dorsolumbar .  100 

Lumbar 76 

Of  694  autopsies  on  subjects  with  tuberculosis  of  the  spine. 

The  cer\'ica]  region  was  involved  in  185 26.5  per  cent. 

The  dorsal  region  was  involved  in  310 44.6  per  cent. 

The  lumbar  region  was  involved  in  265 44.3  percent.^ 

The  proportionate  length  of  the  different  sections  of  the  spine 
at  the  age  of  five  years  is,  according  to  Disse:^ 

Cervical 20.2 

Dorsal 45.6 

Lumbar 34.2 

100.0 

It  appears  therefore  that  the  frequency  of  the  disease  in  the 
different  regions  of  the  spine  does  not  correspond  to  the  area, 
as  has  been  suggested,  but  that  it  is  proportionately  much  less 
common  in  the  cervical  and  much  more  common  in  the  dorsal 
region. 

Dollinger.  Frank  and  Gunter.  Area. 

Cervical  .      .      11.7  per  cent.  Cervical       .      .        7.7  per  cent. — 20.2 

Dorsal      .      .      59.6  per  cent.  Dorsal    .      .      .      66.4  per  cent. — 45.6 

Lumbar   .      .      28.6  per  cent.  Lumbar        .      .      25.6  per  cent.- — 34.2 

This  may  be  explained  apparently  by  the  greater  strain  to 
which  the  middle  and  lower  parts  of  the  spine  are  subjected,  as 
well  as  by  the  relative  proportion  of  cancellous  tissue  which  offers 
the  opportunity  for  infection. 

It  may  be  noted  in  this  connection  that  the  proportionate 
length  of  the  sections  of  the  spine  changes  somewhat  with  the 
age,  as  is  illustrated  bv  the  folloAving  table,  the  scale  being 
1000.^ 

Cervical.  Thoracic.  Lumbar. 

At  birth 240  490  260 

Three  years     .......  214  479  306 

Five  years 206  486  308 

Eleven  years 209  500  290 

Fourteen  years 216  500  284 

Adult 195  482  323 

1  Humphries  and  Durham:  Jour.  Am.  Med.  Assn.,  Januarj-  27,  1917. 

2  Billroth-Menzel:  Loc.  cit.  s  Skeletlehre,   1896. 
*  Moser:  Handb.  der  orthop.  Chir.,  Joachimsthal,  1905,  p.  521. 


PROGNOSIS  25 

Prognosis. — The  prognosis  in  tuberculous  disease  is  discussed 
in  Chapter  V.  Pott's  disease  is  the  most  dangerous  of  the  tuber- 
culous affections  of  the  bones  or  joints,  because  of  the  relative 
importance  of  the  structure  affected  and  of  the  parts  lying  in 
contact  with  it. 

It  is  evident  also  that  the  degree  of  deformity  and  its  situa- 
.tion  have  a  direct  influence  on  the  prognosis.  In  disease  of  either 
extremity  of  the  spine  the  direct  deformity  is  insignificant  and  the 
secondary  effect  upon  the  trunk  is  slight. 

In  the  typical  "hump-back"  deformity,  however,  the  con- 
tents of  the  thorax  and  abdomen  are  compressed;  the  blood- 
vessels 'are  distorted,  and  the  calibre  of  the  aorta,  which  is  more 
directly  affected,  is  often  much  diminished;  respiration  is  made 
difficult,  and  the  circulation  is  impeded;  as  a  consequence  the 
heart  is  usually  hypertrophied  and  valvular  insufficiency  is  not 
infrequent.  Thus  the  vital  functions  which  are  carried  on  at 
a  disadvantage  at  all  times  may  be  overtaxed  by  the  strain  of 
unfavorable  surroundings,  overwork,  or  disease.  It  is  a  matter 
of  common  observation  that  few  of  those  who  are  markedly  de- 
formed reach  old  age.  On  the  other  hand,  it  may  be  assumed 
that  slight  deformities,  or  those  which  do  not  as  directly  inter- 
fere with  the  vital  functions,  exercise  but  little  influence  upon 
the  future  well-being  of  the  patient.  Seemanni  has  reported  on  the 
later  results  in  182  cases  treated  in  Garre's  Clinic.  Of  those  in  the 
first  ten  years  of  life  after  a  period  of  twelve  years,  40  per  cent,  were 
dead,  50  per  cent,  cured,  disease  still  active  in  10  per  cent.  Of  the 
older  cases  50  per  cent,  were  dead,  and  in  25  per  cent,  the  disease 
was  stiU  present.  In  a  total  517  patients  under  sixteen  years  of  age 
treated  at  the  New  York  Orthopedic  Hospital  between  1895  and 
1910,  271  could  be  traced.  Of  these  112  were  dead  in  1916— 
38.6  per  cent. 

Although  the  absolute  mortality  of  Pott's  disease  cannot  be 
accurately  estimated,  it  may  be  stated  that  at  least  20  per  cent, 
of  ah  patients  die  during  the  progress  of  the  disease  and  within 
a  few  years  after  its  onset,  from  causes  directly  or  indirectly  de- 
pendent upon  the  local  lesion.  Some  of  these  die  from  general 
dissemination  of  the  tuberculous  infection  and  tuberculous  menin- 
gitis; some  from  exhaustion  following  septic  infection  and  persistent 
suppuration,  or  from  amyloid  degeneration  of  the  internal  organs; 
some  from  tuberculosis  of  the  lungs,  and  many  from  intercurrent 
affections  that  are  fatal  because  of  the  devitalizing  influence  of  the 
disease  and  its  complications. 

The  prognosis  of  Pott's  disease  in  the  individual  case  is  in- 
fluenced by  many  considerations.  In  one  instance  the  family 
history  is  good,   the  surroundings  are  favorable,  the  patient  is 

1  Beitr.  z.  klin.  Chir.,  Ixxxvii,  Heft  1. 


26  TUBERCULOUS  DISEASE  OF   THE  SPINE 

in  good  condition,  and  the  disease  is  localized;  one  is  then  inclined 
to  look  upon  it  as  an  accident,  and  hardly  considers  the  possibility 
of  a  fatal  termination;  while  in  another  case  the  weakness  and  under- 
vitalization  of  the  body  are  so  evident  that  the  affection  of  the  spine 
seems  but  an  incident  of  a  general  degeneration. 

Symptoms. — The  most  obvious  sign  of  Pott's  disease  is  deformity. 
At  an  early  stage  of  the  process  there  may  be  but  a  slight  irregu- 
larity in  the  contour  of  the  spine,  and  if  several  adjacent  vertebral 
bodies  are  affected  the  projection  may  be  somewhat  rounded  in 
outline;  but  as  compared  with  other  deformities  of  the  spine,  that 
of  Pott's  disease  is  characteristically  angular,  and  as  its  cause  is  loss 
of  substance,  its  formation  is  accompanied  by  and  must  have  been 
preceded  by  the  symptoms  of  bone  disease. 

Deformity  is  thus  the  evidence  of  a  destructive  process  that 
may  have  existed  for  months  and  only  by  its  early  recognition 
can  the  ideal  result  be  attained.  The  spine  which,  although 
weak,  is  still  straight  may  be  held  straight;  but  when  the  de- 
formity is  present,  it  can  be  remedied  only  in  part,  and  it  may 
be  difficult  even  to  check  its  progress.  For  as  the  upper  seg- 
ment of  the  spine  sinks  forward  and  downward  the  influences 
of  compression  and  attrition  increase  the  activity  of  the  local 
process  and  aggravate  its  effects. 

Formerly  angular  deformity  was  thought  to  be  the  essential 
sign  of  Pott's  disease,  and  even  now  the  fact  is  not  generally 
recognized  that  the  detection  of  the  disease  in  its  inception  is 
both  possible  and  easy,  if  one  will  apply  the  same  methods  that 
serve  for  the  diagnosis  of  other  affections  not  attended  by  a  symp- 
tom so  obvious  as  external  deformity.  It  is  to  such  application 
of  the  principles  of  differential  diagnosis  that  attention  is  called. 

The  spine  is  the  chief  support  of  the  body,  possessing  a  free 
mobility  that  accommodates  it  to  every  movement  of  the  body. 
It  is  evident,  therefore,  that  the  symptoms  of  a  destructive  disease 
must  be  pain,  weakness,  and  impairment  of  normal  motion.  Motion 
and  support  are  not,  however,  the  only  functions  of  the  spine;  it 
contains  the  spinal  cord,  from  which  branch  the  nerves  that  supply 
the  organs  and  members  of  the  body.  This  may  be  implicated  at 
an  early  stage  of  the  affection  and  the  sudden  onset  of  paralysis 
may  overshadow  the  symptoms  of  the  original  disease.  In  other 
instances  the  tumor  of  an  abscess — one  of  the  common  accompani- 
ments of  tuberculous  disease — may  interfere  with  the  functions  of 
important  parts  lying  in  the  neighborhood  of  the  spine,  and  peculiar 
symptoms,  due  to  this  cause,  may  attract  attention  before  the 
primary  disease  is  suspected.  Such  s^-mptoms  may  be  mislead- 
ing and  it  is  well,  therefore,  to  consider  them  apart  from  those 
that  indicate  the  primary  effect  of  the  disease  upon  the  spine. 
These  direct  symptoms  usually  precede  and  always  accompany 
the  secondary  or  complicating  s^^nptoms,  and  upon  them  the 
diagnosis  depends. 


SYMPTOMS  27 

The  primary  and  diagnostic  symptoms  of  Pott's  disease  may 
be  classified  as  follows : 
(a)  Pain. 
(h)  Stiflfness. 
((?)  Weakness. 

(d)  Awkwardness. 

(e)  Deformity. 

(a)  Pain. — At  first  thought  one  might  expect  the  pain  of  Pott's 
disease  to  be  localized  at  the  affected  vertebrae,  and  to  be  accom- 
panied by  sensitiveness  to  pressure  or  even  by  infiltration  and  swell- 
ing of  the  neighboring  tissues;  but  it  will  be  remembered  that  the 
bodies'  of^the  vertebrae  are  in  the  interior  of  the  trunk,  practically 
speaking,  as  near  to  its  anterior  as  to  its  posterior  surface  (Fig.  9), 
and  that  the  products  of  the  disease  pass  downward  and  forward, 
rarely  backward.  Thus  sensitiveness  to  pressure  on  the  projecting 
spinous  processes  is  unusual,  and  palpation,  except  in  the  cervical 
region,  is  of  comparatively  little  diagnostic  value. 

The  pain  of  Pott's  disease  is  not  localized  in  the  neighborhood 
of  the  disease,  because  the  filaments  that  supply  the  bodies  of  the 
vertebrae  are  insignificant  parts  of  nerves  that  are  distributed  to 
distant  points — to  the  head,  to  the  limbs,  to  the  front  and  sides  of 
the  trunk — and  to  these  parts  the  pain  is  referred;  thus  "earache" 
or  "stomach-ache"  or  "sciatica"  may  be  symptomatic  of  Pott's 
disease.  The  pain  is  by  no  means  constant;  it  is  induced  by  jars 
or  by  sudden  or  unguarded  movements.  It  is  often  worse  at  night, 
when,  after  the  relaxation  of  the  muscular  tension  that  has  protected 
the  part,  the  unconscious  movements  during  sleep  cause  discomfort, 
and  the  child  moans  in  its  sleep,  or  is  restless,  and  sometimes  it 
wakes  with  a  cry — "'night  cry." 

(b)  Impairment  of  Function  or  Loss  of  Normal  Mobility:  Stiff- 
ness.— Stiffness  is  in  part  voluntary,  in  the  sense  that  the  patient 
adapts  his  movements  and  attitudes  to  the  sensitive  spine,  but 
the  essential  stiffness  of  Pott's  disease  is  caused  by  the  involun- 
tary muscular  tension  and  contraction  of  the  muscles.  This 
reflex  muscular  spasm  varies  in  degree,  according  to  the  state  of 
the  underlying  disease.  It  may  fix  the  spine  or  it  may  check  only 
the  extremes  of  motion,  but  it  is  always  present,  preceding  deformity 
and  accompanying  it  until  cure  is  established;  thus  it  is  the  most 
important  of  the  diagnostic  symptoms  of  Pott's  disease. 

(c)  Weakness. — As  the  disease  affects  the  most  important  sup- 
port of  the  body,  it  is  a  direct  as  well  as  an  indirect  cause  of  weak- 
ness, and  the  more  vulnerable  the  spine  the  more  pronounced  is 
this  symptom;  thus  in  a  young  child,  "loss  of  walk,"  the  refusal 
to  stand,  and  the  instinctive  desire  for  support,  are  the  symptoms 
that  first  call  attention  to  the  local  disease. 

(f/)  Change  in  Attitude:  Awkwardness. — This  really  sums  up 
the  effects  of  the  preceding  symptoms,  since  it  is  evident  that 


28 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


pain,  weakness,  and  stiffness,  must  cause  a  change  in  appearance 
and  in  the  habitual  attitudes  of  the  patient.  Such  s^Tiiptomatic 
attitudes  may  be  almost  diagnostic  of  the  disease  and  of  the  part 
of  the  spine  involved. 

(e)  Change  in  the  Contour  of  the  Spine:  Deformity. — The  deform- 
ities of  Pott's  disease  may  be  classified  as: 

1.  Bone  deformity. 

2.  Muscular  deformity. 

3.  Compensatory  deformity. 

The  characteristic  angular  projection   caused  by  destruction  of 
bone  has  been  described  already. 

^luscular  deformity  is  the  distortion  due  to  muscular  spasm  or 
contraction.   Of  this  the  wry-neck,  sATnptomatic  of  cervical  disease, 
and  psoas  contraction  in  the  lower  region 
of  the  spine  are   the    most    familiar    ex- 
amples. 

Compensatory  deformity  signifies  the 
more  general  eft'ect  of  the  local  disease 
and  local  distortion  upon  the  spine  as  a 
whole  (Fig.  5).  Thus  an  angular  projec- 
tion must  be  balanced  by  a  compensatory 
incurvation,  and  lateral  distortion  in  one 
direction  by  lateral  distortion  in  another. 

These  three  deformities  are,  of  course, 
nearly  related,  and  they  are  usually  com- 
bined, although  muscular  distortion  may 
precede  the  stage  of  bone  destruction, 
while  the  compensatory  changes  are  not 
immediately  apparent.  On  the  other  hand, 
the  secondary  changes  in  the  contoiu'  of. 
the  spine  may  catch  the  eye  before  the 
primary  local  deformity  is  detected. 

Lateral  deviation  of  the  spine  is  not 
infrequent;  it  may  be  a  direct  distortion 
at  the  seat  of  the  disease,  caused  by  the 
destruction  of  the  side  of  a  vertebral  body 
(Fig.  22) ,  but  more  often  it  is  a  secondary 
effect  of  such  irregular  erosion  at  one  or 
the  other  extremity  of  the  spine,  or  the 
effect  of  muscular  contraction,  or  it  may 
be  due  to  simple  weakness,  in  which  case 
it  is  a  transient  symptom. 
Finally,  even  in  incipient  cases,  there  is  almost  always  a  slight 
change  in  the  outline  of  the  spine  due  to  local  rigidity;  the  spine 
no  longer  forms  a  long,  regular  curve  when  the  body  is  bent  for- 
ward, but  the  outline  is  broken  at  or  near  the  seat  of  the  disease 
(Fig.  7).  • 


Fig.  5. — A,  direct  de- 
formity; B,  compensatorj- 
deformity.  The  dotted  line 
indicates  the  normal  con- 
tour of  the  spine. 


GENERAL  SYMPTOMS 


29 


Secondary  or  Complicating  Symptoms. — (a)  Abscess. — ^This 
may,  by  its  size  or  situation,  cause  peculiar  s;^Tnptoms.  In  the 
retropharyngeal  space  it  may  interfere  with  respiration  and 
deglutition.  In  the  thoracic  region  it  might  be  mistaken  for 
pleurisy  or  empyema,  and  when  it  forms  a  tumor  in  the  iliac  fossa 
it  may  interfere  with  locomotion. 

(b)  Paralysis. — ^This  is  usually  a  late  symptom,  but  if  the  dis- 
ease begins  in  the  centre  or  posterior  part  of  a  vertebral  body  it 
may  implicate  the  spinal  cord  before  deformity  is  apparent. 

Abscess  and  paralysis  are  symptoms  that  may  be  explained 
by  Pott's  disease,  but  other  than  by  calling  attention  to  disease 
of  the  spine  as  a  possible  cause  of  the  complication,  they  do  not 
aid  one  in  determining  the  diagnosis;  for  this  reason  they  are 
classed  as  secondary  symptoms. 


Fig.  6. — Normal  contour  and  flexibility  of  the  spine. 


General  Symptoms. — Especial  stress  is  laid  by  certain  writers 
upon  the  diagnostic  value  of  a  slight  but  constant  elevation  of 
the  temperature.  This  is  usually  present  if  the  disease  is  active 
or  when  an  abscess  is  approaching  the  surface,  but  the  positive 
value  of  the  symptom  in  early  or  quiescent  cases  is  doubtful. 
It  may  be  assumed  also  that  a  patient  suffering  from  tubercu- 
lous disease  of  the  spine  will  present  some  evidence  of  a  painful 
and  depressing  affection,  or  of  inherited  or  acquired  weakness; 
yet  it  must  be  remembered  that  the  absence  of  such  general 
symptoms  would  not  exclude  Pott's  disease. 

The  Contour  and  Flexibility  of  the  Spine. — In  the  enumeration 
of  the  early  symptoms  of  Pott's  disease,  two  have  been  noted 
as  of  especial  importance — the  impairment  of  normal  mobility 
and  the  effect  of  the  disease  upon  the  contour  of  the  spine  and 


30  TUBERCULOUS  DISEASE  OF   THE  SPINE 

upon  the  attitudes  of  the  patient.  Therefore  in  the  study  of  the 
normal  spine  the  standard  with  which  that  suspected  of  disease 
must  be  compared,  mobility  and  contour,  at  different  ages  and 
under  dift'ernt  conditions  should  receive  especial  consideration. 

The  spine  as  a  whole  is  a  flexible  column  presenting  certain 
constant  curves,  forward  in  the  upper,  backward  in  the  middle, 
and  forward  again  in  the  lower  region.  These  curves  are  essen- 
tially the  effect  of  the  force  of  gravity  and  of  the  action  of  the 
muscles  in  balancing  the  weight  of  the  body  in  the  upright  atti- 


f 

m 

71 

^^^^^^^Pr 

Wm         ^^H 

^^^^^^H^^r 

- 

^^H 

^^^1 

^^K  v"^^ 

/■^^^^l 

Fig.  7. — ^Incipient  Pott's  disease.     Showing  the  break  in  the  contour  of  the  spine,  of 
which  the  normal  f3exibiUtj^  is  but  slightly  impaired. 

tude.  In  the  adult  they  are  practically  fixed;  in  early  childhood 
they  can  be  nearly  obliterated  by  traction  in  the  horizontal  posi- 
tion; and  in  infancy  they  do  not  exist.  If  the  newborn  infant 
is  placed  in  a  sitting  posture  the  head  falls  forward  and  the  spine 
bends  in  one  long  backward  curve,  characteristic  of  weakness. 
If  when  it  lies  on  the  back  the  legs  are  drawn  down  from  their 
habitual  attitude  of  semiflexion,  it  will  be  noticed  that  the  range 
of  extension  is  somewhat  limited  because  of  the  absence  of  the 
lumbar  curve  and  the  inclination  of  the  pelvis.  When  the  gain 
in  muscular  power  is  sufficient  to  enable  the  infant  to  raise  and  to 


CONTOUR  AND  FLEXIBILITY 


31 


control  the  head,  the  curve  of  the  neck  appears.  Later,  when  the; 
child  stands,  the  erector  spinse  muscles  hold  the  body  upright 
against  the  resistance  of  the  iliopsoas  group  and  of  the  ligaments 
of  the  hip-joints;  thus  the  lumbar  curve  and  the  inclination  of  the 
pelvis  result,  and  the  normal  contour  of  the  spine  is  established. 

If  from  the  odontoid  process  of  the  axis  of  a  normal  indi- 
vidual in  the  erect  posture  a  line  be  dropped  to  the  ground,  this 
perpendicular  or  weight  line,  about  which  the  weight  of  the  body 
is  balanced,  will  indicate  the  curves  of  the  spine,  and  divide  it  into 
sections  that  correspond  sufficiently  well  to  function.  The  cervical 
curve  ends  at  the  second  dorsal  vertebrae,  the  thoracic  curve  at  the 
twelfth  dof sal,  and  the  lumbar  curve  at 
the  sacrovertebral  angle  (Fig.  8). 

What  has  been  spoken  of  as  the 
normal  contour  of  the  spine  varies  con- 
siderably in  the  adult.  It  is  affected  by 
the  occupation  and  by  many  other  cir- 
cumstances; of  this,  the  round  shoulders 
of  the  cobbler  or  the  weaver,  the  stoop  of 
weakness,  of  old  age,  and  the  like  are 
familiar  examples;  but  in  childhood 
distinct  variations  from  the  normal 
contour  almost  always  have  a  clearly 
defined  pathological  cause.  As  the 
normal  contour  is  the  effect  of  the 
balancing  of  the  body  in  the  upright 
posture,  it  is  evident  that  if  the  outline 
of  one  part  is  permanently  changed 
compensation  for  this  change  must  be 
made  in  another  part.  Thus  when  de- 
formity is  well  marked,  the  normal  curves 
of  the  spine  are  often  completely  reversed 
(Fig.  5),  and  even  in  early  cases  the  ab- 
normal contour  may  attract  attention 
before  local  deformity  is  noticeable. 

Divisions  of  the  Spine. — Although  the  spine  is  a  flexible  column 
whose  outline  changes  with  every  movement  and  posture  yet  the 
range  and  character  of  this  motion  vary  greatly  in  different  parts. 
In  the  cervical  and  lumbar  regions  the  range  is  extensive,  because 
of  the  relatively  large  proportion  of  elastic  intervertebral  sub- 
stance, because  of  the  direction  of  the  articular  surfaces,  and  be- 
cause the  spine  is  near  the  centre  of  the  body.  Motion  is  very 
limited  in  the  thoracic  region,  because  the  intervertebral  disks 
are  thin,  because  of  the  overlapping  spinous  processes,  and  because 
it  forms  a  paxt  of  the  rigid  thorax.  Where  free  notion  is  essential 
to  the  habitual  attitudes,  interference  with  normal  motion,  and  the 
other  attendant  symptoms  of  disease  will  be  apparent  earliest. 


Fig.  8. — The    divisions 
the  spine. 


of 


32 


TUBERCULOUS  DISEASE  OF   THE  SPIXE 


Thus  one  more  often  has  the  opportunity  for  early  diagnosis  in 
disease  of  the  lumbar  and  cervical  regions  because  in  the  one  the 


"^^ 


•«*^; 


'^■^■^ 


lumu^g 


Aorta/ 


phr^ 


e.n^ 


V<^' 


J,^ 


motions  necessary  in  stooping,  sitting,  and  standing  are  constrained, 
and  in  the  other  the  neck  is  stiff,  or  the  head  is  tm-ned  or  drawn  from 
the  normal  line.     In  the  thoracic  region  earlv  diagnosis  is  less  often 


LANDMARKS  33 

made,  because  in  this  section  motion  is  so  unimportant  that  its 
restraint  may  escape  the  attention  of  the  patient  or  parent.  In 
considering  diagnosis,  therefore,  and,  in  fact,  treatment  and  prog- 
nosis, one  should  divide  the  spine  into  three  sections  to  correspond 
with  function : 

1.  The  neck  part,  that  permits  free  motion  of  the  head,  end- 
ing at  the  third  dorsal  vertebrae. 

2.  The  rigid  thoracic  part,  which  includes  the  third  and  the 
tenth  dorsal  vertebrse. 

3.  The  lower  part,  made  up  of  the  lower  two  dorsal  and  the 
lumbar  vertebrae,  in  which  the  principal  movements  of  the  trunk 
are  carried  out  (Fig.  8). 

One  must  bear  in  mind  the  distribution  of  the  nerves,  because 
the  characteristic  pain  is  referred  to  their  terminations,  also 
the  parts  in  relation  to  the  spine  at  different  levels  that  may  be 
implicated  in  the  disease.  Thus  remembering  that  the  symp- 
toms of  Pott's  disease  are  in  general,  stiffness,  weakness,  pain 
and  deformity,  one  will  always  apply  these  symptoms  to  a  par- 
ticular region  of  the  spine,  and  will  picture  to  himself  the  effect 
of  such  stiffness,  weakness,  and  deformity  at  this  or  at  that  verte- 
bra; the  effect  of  an  abscess  in  this  or  that  situation,  and  the 
area  of  paralysis  that  might  be  caused  by  pressure  on  the  cord 
at  one  or  another  level. 

Landmarks. — The  atlas  is  on  a  line  with  the  hard  palate. 

The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth. 

The  transverse  process  of  the  atlas  is  just  below  and  in  front 
of  the  tip  of  the  mastoid  process. 

The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  vertebra. 

The  upper  margin  of  the  sternum  is  opposite  the  disk,  between 
the  second  and  third  dorsal  vertebra.  The  junction  of  the  first 
and  second  sections  of  the  sternum  is  opposite  the  fourth  dorsal 
vertebra. 

The  tip  of  the  ensiform  cartilage  is  opposite  the  lower  part  of 
the  body  of  the  tenth  dorsal  vertebra. 

The  anterior  extremity  of  the  first  rib  is  on  a  line  with  the  fourth 
rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  with  the  ninth, 
and  the  seventh  with  the  eleventh. 

The  scapula  overlaps  the  second  and  the  seventh  ribs,  its  lower 
angle  being  opposite  the  centre  of  the  eighth  dorsal  vertebra. 

The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and 
the  interval  between  the  second  and  third  dorsal  spines  are  in  the 
same  plane. 

The  most  constant  landmark  from  which  to  count  is  the  spin- 
ous process  of  the  fourth  lumbar  vertebra,  which  is  on  a  line  with 
the  highest  point  of  the  crest  of  the  ilium.     The  umbilicus  is  near 
the  same  plane. 
3 


34  TUBERCULOUS  DISEASE  OF   THE  SPINE 

The  Inclination  of  the  Pelvis. — In  the  erect  attitude  the  plane 
of  the  brim  forms  an  angle  of  50  degrees  to  60  degrees  with  the 
horizon.^ 

The  tip  of  the  cocc^'x  is  opposite  the  lower  border  of  the  sym- 
physis pubis. 

Length  of  the  Spinal  Cord. — In  the  adult  the  spinal  cord  ter- 
minates at  the  lower  margin  of  the  first  lumbar  vertebra.  At 
birth  it  extends  to  the  third  lumbar  vertebra  and  its  membranes 
to  the  second  division  of  the  sacrum. 

The  Intervertebral  Disks. — In  the  adult  the  intervertebral  disks 
form  41.9  per  cent,  of  the  cervical,  26.4  per  cent,  of  the  dorsal, 
and  44.6  per  cent,  of  the  lumbar  regions  of  the  spine  (Dwight). 

The  character  of  the  disease,  its  manifestations,  and  its  effects 
upon  the  spine  having  been  outlined,  the  student  is  now  brought, 
as  it  were,  into  actual  contact  with  the  patient  and  his  family. 
And  as  Pott's  disease  is  the  most  important  of  the  chronic  affec- 
tions of  childhood,  it  will  serve  as  a  type  to  illustrate  methods 
of  examination  and  of  treatment  as  applied  in  orthopedic  practice. 

The  Rational  Signs. — The  symptoms  of  Pott's  disease  vary 
decidedly,  not  only  with  the  region  of  the  spine  involved,  but 
also  with  the  age  and  surroundings  of  the  patient.  Like  other 
forms  of  tuberculous  disease  it  is  an  insidious  chronic  affection, 
and  its  early  symptoms  may  fail  to  attract  attention,  because 
they  are  irregular  or  intermittent.  It  is  often  after  a  fall  or  vio- 
lent play  that  the  evidences  of  pain  or  weakness  can  no  longer 
be  overlooked,  so  that  injury  is  likely  to  occupy  a  prominent 
place  in  the  history. 

History. — The  account  of  the  disease  given  by  the  parent  is 
usually  indefinite  and  misleading.  Certain  points,  however,  of 
relative  importance  may  be  ascertained  by  the  following  ques- 
tions: 

One  asks  if  the  immediate  relatives  of  the  child  have  suffered 
from  phthisis  or  other  form  of  tuberculosis,  as  this  might  indi- 
cate a  predisposition  to  disease,  and  thus  affect  the  prognosis. 

One  asks  if  the  child  has  been  robust  or  the  reverse,  and  if  re- 
covery from  the  ordinary  ailments  of  childhood  was  prompt  or 
tedious,  in  order  that  one  may  judge  of  the  quality  of  the  patient. 

One  next  asks,  not  "How  long  has  the  child  been  ill?"  for  this 
is  usually  understood  to  refer  to  the  duration  of  the  more  decided 
symptoms,  but  "When  was  the  child  last  perfectly  well?"  One 
asks  particularly  as  to  the  onset  of  the  first  symptoms  whether 
it  was  sharp  and  decided,  or  gradual  and  ill-defined;  if  the  symp- 
toms were  preceded  by  contagious  disease.  This  latter  is  an  impor- 
tant question,  because  measles,  for  example,  predisposes  to  tuber- 
culous infection  or  at  least  to  its  local  outbreak,  and  diphtheria 

1  Men,  54.17;  Women,  51.72.  Prochvnik:  Archiv  f.  Gynec,  1882,  xis,  1.  This 
inclination  is  increased  when  the  thighs  are  abducted  to  the  full  limit. 


PHYSICAL  SIGNS  35 

Is  often  followed  by  paralysis  or  by  weakness  that  may  simulate 
certain  symptoms  of  Pott's  disease.  The  character  of  the  injury 
that  almost  every  patient  is  supposed  to  have  received  is  then 
investigated.  It  should  be  made  clear  whether  the  injury  was  the 
direct  cause  of  the  symptoms,  or  if  it  may  have  simply  aggra- 
vated or  brought  to  light  the  dormant  disease  or  if,  as  is  often  the 
case,  there  is  simply  an  indefinite  remembrance  of  an  injury  which 
has  no  connection  with  the  symptoms. 

To  establish  injury  as  the  direct  cause  of  symptoms,  the  patient 
must  have  been  well  at  the  time  of  the  accident,  the  symptoms 
must  have  followed  immediately  and  must  have  persisted  since; 
and  finally,  the  symptoms  must  be  of  a  nature  to  be  explained  by 
a  definite  injury. 

By  careful  questioning  one  may  usually  determine  whether 
the  symptoms  of  which  the  patient  complains  are  acute  or  chronic. 
This  is  of  importance  because  tuberculosis  is  a  chronic  disease — 
one  of  the  few  chronic  diseases  of  childhood — although  its  exacer- 
bations may  resemble  the  symptoms  of  acute  disease  or  even  injury. 

However  important  a  correct  histdrj^  may  be,  it  is  upon  the 
physical  examination  that  the  diagnosis  practically  depends. 

Physical  Signs. — The  physical  examination  begins  with  in- 
spection when  one  notes  the  general  condition  and  the  actions 
and  postures  of  the  patient. 

Voluntary  actions  and  attitudes  are  important,  because  they 
show  the  adaptation  of  the  body  to  the  disease,  the  conscious 
and  unconscious  efforts  of  the  patient  to  guard  the  weak  part 
from  strain  and  from  motions  that  caused  discomfort  and  pain. 
Direct  inspection,  palpation,  and  the  tests  of  voluntary  and  pas- 
sive motion  are  of  still  greater  importance,  because  by  such  means 
one  may  demonstrate  the  presence  of  disease  and  localize  it  with 
accuracy. 

The  examination  must  be  purposeful.  When  one  asks  the 
patient  to  pick  up  a  coin  from  the  floor,  it  is  to  test  the  lower  region 
of  the  spine  for  the  symptoms  of  weakness  and  stiffness.  The 
ability  to  perform  the  act  with  ease  by  no  means  excludes  disease 
of  the  spine  in  the  regions  not  especially  involved  in  the  movements 
of  stooping  or  turning  the  body,  although  this  would  appear  to 
be  the  general  belief. 

Such  tests  must  not  only  be  purposeful,  but  they  must  be  adapted 
to  the  age  and  intelligence  of  the  patient.  The  child  that  refuses 
to  pick  up  a  coin  will  often  gather  up  its  clothing,  because  it  wishes 
to  be  clothed  again.  If  it  will  not  stoop,  it  will  rise  usually  if  placed 
in  the  recumbent  or  sitting  posture — an  equally  useful  test.  A 
child  will  walk  toward  its  mother  if  placed  at  a  distance  from  her. 
It  will  always  turn  its  head  toward  her;  thus  voluntary  motion 
of  the  cervical  region  may  be  tested  by  changing  the  mother's 
position,  while  the  child  is  held  by  the  examiner.     Young  children 


36  TUBERCULOUS   DISEASE  OF   THE  SPINE 

that  struggle  and  resist  passive  motion  if  placed  on  the  table, 
submit  quietly  when  held  in  the  mother's  arms. 

Various  simple  and  effective  tests  will  suggest  themselves  to 
the  examiner  who  has  a  definite  purpose  in  view,  but  much  patience 
may  be  required  in  early  cases,  and  several  examinations  may  be 
necessary  before  the  presence  or  absence  of  disease  can  be  definitely 
determined.  It  is  important  to  remember  that  in  childhood,  at 
least,  abnormal  symptoms  always  have  a  cause ;  therefore  a  patient 
should  be  kept  under  observation  until  the  cause  is  discovered. 

Of  all  the  early  signs  of  Pott's  disease  restriction  of  motion  due 
to  reflex  muscular  contraction  is  the  most  important,  since  it  pre- 
cedes deformity  and  accompanies  it  until  cure  is  finally  established. 
This  muscular  resistance  limits  motion  in  all  directions;  thus  it 
may  be  distinguished  from  the  spasm  or  contraction  of  certain 
groups  of  muscles  caused  by  irritation  or  inflammation  not  con- 
nected with  the  spine,  for  in  such  instances  motion  is  limited  only 
in  the  directions  directly  opposed  by  the  muscular  contraction. 
True  reflex  muscular  spasm  is  quite  independent  of  the  will,  and  thus 
it  may  be  distinguished  from  simple  voluntary  resistance  on  the 
part  of  the  patient. 

The  muscular  resistance  is  most  marked  in  the  neighborhood 
of  the  disease,  but  it  extends  to  a  greater  or  less  distance  accord- 
ing to  the  acuteness  of  the  local  process  and  the  susceptibility 
of  the  patient. 

Even  in  early  cases  the  situation  of  the  disease  is  usually  shown 
by  a  slight  irregularity  of  the  spine  in  the  centre  of  the  area  made 
rigid  by  muscular  spasm,  as  well  as  by  the  change  of  contour. 
This  change  in  outline  and  in  flexibility  may  be  demonstrated  by 
bending  the  patient  forward.  If  the  spine  forms  a  long,  even, 
regular  curve,  and  if  there  is  no  evidence  of  pain  or  stiffness  when 
such  an  attitude  is  assumed.  Pott's  disease  is  extremely  improbable. 
If,  on  the  other  hand,  the  outline  of  the  curve  is  broken;  if  the 
motion  of  one  section  of  the  spine  is  restrained,  disease  may  be  sus- 
pected; and  if  other  evidence  of  tuberculous  ostitis  is  present,  the 
diagnosis  maj^  be  made  with  certainty  (Figs.  6  and  7). 

By  a  careful  physical  examination  one  may  expect  to  detect 
Pott's  disease  at  its  inception  and  to  fix  upon  its  location,  or  at 
least  upon  the  point  suspected  of  disease.  One  will  then  ask 
oneself  if  tuberculous  disease  of  the  bodies  of  the  vertebrse  of 
this  particular  region  will  satisfactorily  explain  all  the  symptoms; 
if,  for  example,  the  pain  corresponds  to  the  distribution  of  the  nerves; 
if  restraint  of  function  will  explain  the  attitudes  of  the  patient, 
and  if  the  change  in  contour  is  significant  of  a  destructive  process. 

As  has  been  stated  the  s^onptoms  and  the  eft'ects  of  the  disease 
dift'er  according  to  the  function  of  the  part  of  the  spine  involved, 
and  the  further  examination  should  be  conducted,  therefore, 
from  this  stand-point. 


REGIONAL  EXAMINATION 


n 


1.  Regional  Examination:  the  Lower  Region.— Considering  the 
regions  of  the  spine  in  the  order  of  HabiHty  to  disease  one  begins 
with  the  lower  section,  comprising  the  lumbar  and  the  two  lower 
dorsal  vertebrae,  that  more  nearly  correspond  in  shape  and  function 
to  the  lumbar  than  to  the  thoracic  division. 

This  is  the  region  of  free  and  extensive  motion;  thus  the  painful 
stiffness,  characteristic  of  the  disease,  is  usually  evident  long  be- 
fore the  stage  of  bone  destruction. 


Fig.  10. — Disease  of  the  upper  lum- 
bar region  before  the  stage  of  deformity, 
showing  abnormal  lordosis. 


Fig.   11. — The  same  patient  (Fig.  10) 
five   years  later,   showing   deformity. 


The  characteristic  attitude  of  the  patient  is  one  of  what  might 
be  called  overerectness,  and  in  many  instances  there  is  an  in- 
creased hollowness  of  the  back  (lordosis,  Figs.  10  and  12);  thus 
the  prominent  abdomen  may  first  attract  attention.  The  walk 
is  careful,  and  a  peculiar  tip-toeing  step,  the  feet  being  slightly 
inverted  to  avoid  the  jar  of  striking  the  heels,  is  often  observed; 
this  is,  however,  not  a  peculiarity  of  disease  of  this  region  alone, 
but  is  rather  an  evidence  that  the  spine  is  sensitive  to  slight  jars. 


38  TUBERCULOUS  DISEASE  OF  THE  SPINE 

More  characteristic  of  lumbar  disease  is  a  peculiar  swagger  explained 
in  part  by  the  exaggerated  lordosis,  and  in  part  by  the  loss  of  the 
accommodative,  balancing  motion  of  the  lumbar  spine,  as  the  weight 
falls  alternately  on  each  limb  in  walking. 

The  increased  lumbar  lordosis,  so  characteristic  of  the  early 
stage  of  the  disease,  is  capable  of  several  explanations.  It  is 
partly  voluntary,  as  bending  the  trunk  forward  brings  pressure 
upon  the  diseased  vertebral  bodies,  so  bending  it  backward 
relieves  this  pressure.  It  is  partly  involuntary,  caused  by  the 
contraction  of  the  large  muscular  masses  on  the  posterior  aspect 
of  the  spine;  and  it  is  in  part  compensatory,  as  the  slight  psoas 
contraction  which  is  often  present  has  a  tendency  to  tilt  the  pelvis 
forward,  necessitating  a  greater  compensatory  backward  inclina- 
tion of  the  body. 

As  the  disease  progresses  the  lumbar  section  becomes  straighter, 
and  finally  it  may  project  backward  in  the  characteristic  angular 
deformity.  Yet  even  after  the  lordosis  has  been  obliterated  the 
backward  inclination  of  the  body  still  continues  as  a  compensation 
for  the  change  in  balance,  which  the  transformation  of  the  forward 
curve  to  a  posterior  deformity  has  necessitated  (Fig.  11).  Thus 
overerectness  or  backward  inclination  of  the  body  characterizes 
the  disease  of  this  region  from  its  beginning  to  its  end  in  uncom- 
plicated cases. 

Slight  i^soas  contraction  as  a  part  of  the  general  muscular  spasm 
about  the  diseased  area  simply  increases  the  lordosis;  but  if 
the  contraction  is  greater,  when  for  example  an  abscess  is  present 
which  involves  the  substance  of  the  psoas  muscles  or  forms  a  painful 
tumor  in  the  pelvis,  the  erect  attitude  is  no  longer  possible.  The 
thighs  are  drawn  toward  the  trunk,  and  the  trunk  is  inclined  for- 
ward to  relax  the  tension.  As  this  greater  contraction,  with  the 
abscess  that  is  usually  its  cause,  is  commonly  unilateral  the  patient 
"favors"  the  flexed  limb,  and  the  resulting  limp  is  often  mistaken 
for  a  sign  of  hip  disease.  Unilateral  psoas  contraction,  is  in  fact, 
so  often  present  when  the  patient  is  first  brought  for  treatment, 
that  a  limp  and  the  accompanying  inclination  of  the  body  may  be 
considered  as  characteristic  of  disease  of  the  lumbar  region  at  a 
somewhat  advanced  stage  (Fig.  13). 

The  location  of  the  ixiiri  depends  upon  the  distribution  of  the 
nerves  that  supply  the  diseased  vertebrae  or  that  pass  in  their 
vicinity;  it  may  radiate  over  the  inguinal  region  or  backward  to 
the  loins  or  buttocks  or  down  the  front  or  back  of  the  thighs  to  the 
knees.  Painfid  "cramij'  is  sometimes  a  prominent  symptom; 
the  limb  is  spasmodically  drawn  toward  the  body  and  the  patient, 
seizing  it  with  both  hands,  shrieks  with  pain. 

Latcrial  inclination  of  the  body  is  often  present  particularly  when 
the  disease  is  at  the  lumbosacral  articulation.  It  is  usually  a  symp- 
tom of  unilateral  psoas  contraction  and  abscess;  it  may  be  due 


REGIONAL  EXAMINATION 


39 


also  to  unilateral  contraction  of  the  muscles  of  the  back,  or  at  a 
later  stage  it  may  indicate  collapse  or  destruction  of  one  side  of 
a^  vertebral  body.  In  other  instances  it  is  not  a  fixed  attitude, 
but  is  simply  a  voluntary  adaptation  to  weakness  or  pain;  thus 
one  may  find  a  large  abscess  in  one  pelvic  fossa  unaccompanied 
by  psoas  contraction,  while  the  body  is  inclined  toward  the  opposite 


Fig.   12. — Disease  of  the  lumbar  re- 
gion.   First  symptom,  pain  in  the  knees. 


Fig.  13. — ^Disease  of  the  lumbar 
region  with  right  iliopsoas  abscess  and 
psoas  contraction. 


side,  apparently  because  the  weight  is  supported  habitually  on  this 
limb. 

The  stiffness,  weakness,  and  pain,  characteristic  of  disease  in 
this  region,  are  exemplified  in  many  ways,  for  example,  the  child 
may  be  unable  to  turn  in  bed;  it  is  slow  and  awkward  in  rising 
in  the  morning  or  in  changing  from  an  attitude  of  rest  to  one  of 


40 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


activity.  It  often  prefers  to  stand  rather  than  to  sit,  because  in 
the  latter  position  more  weight  is  thrown  upon  the  sensitive  verte- 
bral bodies.  When  seated,  partic- 
ularly when  riding  in  a  carriage  or 
street^  car,  the  patient  often  sits 
upright,  the  hands  resting  instinc- 
tively on  the  seat  to  steady  and 
support  the  spine. 

Stooping,  a  posture  that  increases 
the  pressure  on  the  diseased  verte- 
bral bodies  and  which  necessitates 
muscular  tension  and  strain  in  re- 
gaining the  erect  position,  is  always 
avoided  by  the  patient  if  the  disease 
is  at  all  acute.  For  example,  when 
the  child  is  asked  to  pick  up  an  ob- 
ject from  the  floor,  it  either  refuses 
or  it  squats  on  the  heels  or  drops 
upon  the  knees  (Fig.  14)  instead  of 
flexing  the  spine  as  in  health.  The 
erect  attitude  is  then  regained  by 
pushing  the  body  up  by  the  pressure 
of  the  hands  on  the  thighs.  If  the 
child  who  refuses  to  stoop  is  placed 
upon  the  floor,  it  will,  if  possible, 
seize  the  mother's  skirts  or  it  will  crawl  to  a  chair  or  other  object 
upon  which  the  body  may  be  drawn  up  by  the  arms,  so  that  the 


Fig.  14.  —  Lumbar    disease.    The 
manner  of  picking  up  an  object. 


Fig.   15. — Showing  the  rigidity  of  the  spine  before  appearance  of  deformity. 


REGIONAL  EXAMINATION 


41 


discomfort  caused  by  contraction  of  the  back  muscles  may  be 
avoided. 

After  the  inspection  of  the  movements  and  attitudes  of  the 
patient  the  direct  examination  of  the  range  of  passive  motion 
is  made.  The  patient  is  placed  at  full  length,  face  downward,  on 
a  table,  and  the  range  of  extension  and  of  lateral  motion  is  tested 
by  lifting  the  legs  and  swaying  the  body  gently  from  side  to  side 
(Fig.  15).  The  spine  is  so  flexible  in  childhood  that  rigidity  even 
in  the  upper  dorsal  region  may  be  demonstrated  by  this  method, 
and  in  testing  the  lumbar  region  the  thorax  should  be  fixed  by  the 
hand.  One  should  then  examine  for  psoas  contraction.  The  pelvis 
is  pressed  firmly  against  the  table  with  one  hand,  while  the  leg, 
held  in  the  line  of  the  body,  is  gently  lifted  by  the  other  (Fig.  16). 


Fig.   16. — Test  for  psoas  contraction. 


The  normal  range  of  hyperextension  at  the  hip-joint  should  allow 
the  knee  to  be  lifted  two  or  three  inches  from  the  table.  Eestric- 
tion  of  extension  of  both  thighs,  indicating  a  slight  degree  of  psoas 
contraction,  is  very  common  in  lumbar  Pott's  disease;  but  when  the 
restriction  is  marked,  and  especially  if  it  is  unilateral,  a  deep  abscess 
may  be  suspected.  Such  unilateral  psoas  contraction  may  be 
demonstrated  by  placing  the  child  on  the  back,  allowing  the  limbs 
to  hang  over  the  edge  of  the  table,  when  the  unaffected  thigh  will 
drop  below  its  fellow  (Fig.  17). 

As  a  rule  flexion  of  the  spine  is  much  more  restricted  in  the 
early  stage  of  the  disease  than  is  extension;  this  may  be  demon- 
strated by  placing  the  child  on  its  hands  and  knees,  and  lifting 
it  from  the  floor,  when  the  body,  instead  of  bending  over  the 
supporting  hands,  retains  almost  its  original  contour  (Fig.  18). 


42 


TUBERCULOUS^DISEASE  OF   THE  SPINE 


As  has  been  stated,  even  in  early  cases  one  may  detect  often 
a  slight  fulness  about  the  spinous  processes  or  a  slight  irregularity 
in  their  line,  about  which  the  muscular  spasm  is  most  marked; 


Fig.   17. — -A  method  of  demonstrating  psoas  contraction. 


Fig.  18. — Disease  of  the  lumbar  region  before  the  stage  of  deformity.     A  test  for 

rigidity. 


DIFFERENTIAL  DIAGNOSIS  43 

this  indicates  the  exact  seat  of  the  disease.  Deep  pressure  on  the 
spinous  processes  may  cause  discomfort,  and  sometimes  greater 
elasticity  at  this  point  may  be  demonstrated.  Except  in  the  hands 
of  an  expert,  it  is,  however,  a  test  of  comparatively  little  value; 
and  again  it  may  be  mentioned  that  local  pain  and  local  sensitive- 
ness to  pressure  on  the  spinous  processes  are  not  characteristic 
signs  of  Pott's  disease. 

Finally,  one  should  examine  for  'jjelvic  abscess.  This  may  be 
suspected  when  unilateral  psoas  contraction  is  present  in  marked 
degree,  although  psoas  contraction  may  be  present  without  abscess, 
and  abscess  may  be  unaccompanied  by  psoas  contraction  when  the 
substance  of  the  muscle  is  not  involved. 

The  typical  psoas  abscess,  as  pictured  and  described,  is  a  fluc- 
tuating tumor  that  suddenly  appears  on  the  inner  side  of  the  thigh, 
although  it  may  have  been  many  months  in  descending  to  this 
position  from  its  original  site.  Demonstrable  abscess  is  present  at 
some  time  in  at  least  50  per  cent,  of  the  cases  of  lumbar  disease, 
and  its  detection  is  a  matter  of  importance,  since  its  subsequent 
behavior  will  often  materially  influence  the  treatment.  The  child 
is  placed  on  the  side,  the  thigh  is  flexed,  and  the  hand  is  pressed 
gently  down  into  the  loin  and  iliac  fossa.  Sometimes  the  examina- 
tion will  be  made  easier  by  extending  the  limb  and  thus  bending 
the  spine  forward  toward  the  hand.  Often  in  this  maimer  one  can 
make  out  a  peculiar  sausage-like  thickening  on  one  or  the  other  side 
of  the  spine,  or  a  larger,  rounded  tumor  in  the  iliac  fossa,  the  pres- 
ence of  which  would  not  otherwise  have  been  suspected. 

Diagnosis. — If  a  careful  physical  examination  were  made  in 
all  suspicious  cases,  by  one  at  all  familiar  with  the  ordinary  symp- 
toms of  Pott's  disease,  the  field  for  difi^erential  diagnosis  would  be 
small  indeed;  but  it  would  appear  that  such  examinations  are  not 
made  usually  by  the  physician  who  is  first  consulted.  One  may 
learn,  for  example,  that  the  child  has  been  circumcised  because 
of  pain  about  the  genitals,  or  because  of  weakness  of  the  limbs, 
supposed  to  be  due  to  "reflex  irritation;"  or  if  the  patient  is  an 
adult,  that  he  has  been  treated  for  sciatica,  rheumatism,  or  strain, 
long  after  the  deformity  even,  would  have  been  apparent  had  the 
back  been  inspected. 

Pott's  disease  is  most  often  mistaken  for  some  one  of  the  following 
affections : 

Lumbago. — This  may  simulate  some  of  the  symptoms  of  Pott's 
disease  of  this  region,  but  it  is  of  sudden  onset,  usually  accompanied 
by  local  pain  and  sensitiveness  of  the  muscles  themselves. 

Strain  of  the  Back. — This  is  often  accompanied  by  stiff- 
ness and  pain  on  motion,  but,  like  lumbago,  its  onset  is  sudden 
and  its  cause  is  known.  The  pain  is  usually  localized  at  the 
point  of  injury;  it  is  relieved  by  rest,  and  the  restriction  of  motion 
is  in  great  degree  voluntary.     In  Pott's  disease  the  pain  is  neu- 


44  TUBERCULOUS  DISEASE  OF   THE  SPINE 

ralgic;  it  is  often  worse  at  night  and  the  rigidity  is  due  to  reflex 
spasm. 

Sciatica. — The  pain  of  sciatica  is  most  often  unilateral;  it  is 
usually  confined  to  the  distribution  of  this  nerve,  which  is  often 
sensitive  to  pressure  throughout  its  course.  The  pain  of  Pott's 
disease,  if  it  is  referred  to  the  limbs,  is  usually  bilateral  and  the 
nerve  trunks   are  not   often   sensitive   to   pressure.      In   sciatica 


Fig.   19. — Disease  of  the  lower  dorsal  region.     The  earliest  indication  of  deformity. 

movements  of  the  limbs  that  cause  tension  on  the  nerve  are  often 
painful,  while  motion  of  the  spine  is  free,  or  but  slightly  restricted, 
the  reverse  of  the  s^^Ilptoms  of  Pott's  disease.  It  is  true  that 
lateral  deviation  and  even  rigidity  of  the  lumbar  spine  are  some- 
times observed  in  cases  of  lumbosciatic  neuralgia  of  long  standing, 
but  if  the  latter  symptom  is  marked  the  diagnosis  may  be  regarded 
as  open  to  question. 


DIFFERENTIAL  DIAGNOSIS  45 

Spondylitis  Deformans.  —  This  disease  is  practically  con- 
fined to  adult  life  and  is  far  more  often  mistaken  for  lumbago 
than  for  tuberculous  disease.  It  is  described  in  detail  in 
Chapter  II. 

Spondylolisthesis. — This  is  a  very  uncommon  affection  in 
early  life.  It  may  simulate  disease  at  the  lumbosacral  articu- 
lation. A  description  of  its  peculiarities  will  be  found  in  Chap- 
ter 11. 

Sacro-iliac  Disease. — Sacro-iliac  disease  is  far  more  likely 
to  be  mistaken  for  disease  of  the  hip-joint  than  of  the  spine; 
the  pain  and  sensitiveness  are  usually  localized  about  the  seat 
of  disease  and  the  movements  of  the  spine  are  not  restricted,  except 
in  cases  of  long  standing. 

Lumbago,  sciatica,  and  sacro-iliac  disease  are  extremely  un- 
common in  childhood,  and  if  supposed  strains  or  injuries  of  the 
spine  cause  persistent  symptoms,  the  appropriate  treatment  would 
be  similar  to  that  of  Pott's  disease;  that  is  to  say,  the  suspected  part 
should  be  supported  until  the  cause  of  the  symptoms  is  made  clear. 

The  attitude  characteristic  of  Pott's  disease  of  this  region, 
the  hollow  back,  the  prominent  abdomen,  and  the  swaying  gait, 
may  be  simulated  by  bilateral  congenital  dislocation  of  the  hip, 
in  which  the  pelvis  is  suspended  at  a  point  behind  its  normal 
position;  but  in  this  instance  the  gait  and  attitude  have  existed 
since  the  child  began  to  walk,  and  the  symptoms  of  the  disease 
are  absent.  A  similar  attitude  is  sometimes  caused  by  weakness 
or  paralysis  of  the  muscles  of  the  back,  as,  for  example,  in  the 
muscular  dystrophies.  In  such  affections  there  may  be  also  a 
disinclination  to  stoop,  and  there  may  be  limitation  of  motion, 
symptoms  that  bear  a  superficial  resemblance  to  Pott's  disease; 
but  as  there  are  no  other  signs  of  disease  of  the  spine,  it  may  be 
readily  excluded. 

When  psoas  contraction  is  present  the  resulting  limp,  often 
accompanied  by  pain  in  the  limb,  is  almost  invariably  mistaken 
for  a  symptom  of  hip  disease. 

Although  flexion  of  the  thigh  caused  by  psoas  contraction  is  a 
common  accompaniment  of  Pott's  disease,  it  is  not  usually  an 
early  symptom;  thus  the  history  will  probably  call  attention  to 
symptoms  referable  to  the  spine,  that  have  preceded  it.  Again, 
the  limp  of  Pott's  disease  is  caused  simply  by  flexion  of  the  limb, 
and  if  the  tension  of  the  contracted  iliopsoas  muscle  is  relieved 
by  flexing  the  thigh  still  further,  the  other  movements  at  the  hip, 
abduction,  adduction,  rotation,  and  flexion,  are  free  and  painless. 
Thus,  hip  disease,  in  which  all  movements  are  restrained  in  equal 
degree  by  muscular  spasm,  may  be  excluded  readily,  except, 
perhaps,  in  infancy. 

Hip  Disease  in  Infancy. — At  this  susceptible  age  sympa- 
thetic spasm  of  the  lumbar  muscles  may  accompany  acute  affec- 


46  TUBERCULOUS  DISEASE  OF   THE  SPINE 

tions  of  the  hip,  and  similar  spasm  of  the  hip  muscles  may  h^^^ 
present  in  Pott's  disease  of  the  lower  part  of  the  spine. 

Several  examinations  may  be  necessary  before  the  exact  loca- 
tion of  the  disease  can  be  determined,  and  in  doubtful  cases  the 
application  of  a  temporary  support  to  the  back  and  thigh,  such 
as  a  spica-plaster  bandage  to  relieve  the  sympathetic  spasm,  is 
useful  as  an  aid  in  diagnosis. 

It  has  been  stated  that  extension  of  the  thigh  only  is  restrained 
by  psoas  contraction.  It  should  be  evident,  however,  that  the  pres- 
ence of  a  large  and  painful  abscess  in  the  pelvis  or  thigh  may  limit 
motion  in  other  directions  as  well;  but  even  in  such  cases  at  least 
one  movement  is  unrestrained;  thus  disease  of  the  joint  may  be 
excluded. 

Seco^'uary  Hip  Disease.  —  In  Pott's  disease  of  long  stand- 
ing, complicated  by  abscess,  in  which  the  tissues  about  the  joint 
are  infiltrated  or  traversed  by  discharging  sinuses,  secondary 
infection  of  the  hip-joint  is  not  an  unusual  complication.  In 
such  cases,  when  the  limb  is  distorted  and  when  motion  at  the 
hip  is  limited  by  the  sensitive  and  contracted  tissues,  it  is  not 
easy  to  determine  the  presence  or  absence  of  joint  disease. 
Doubtful  cases  of  this  class  should  be  treated  symptomatically. 

Pelvic  Abscess. — As  abscess  is  such  a  common  complica- 
tion of  Pott's  disease,  it  will  be  necessary  to  consider  abscesses  of 
other  origin,  that  may  cause  occasionally  symptoms  resembling 
somewhat  those  of  disease  of  the  spine.  Such  are  the  peri- 
nephritic  abscess,  and,  more  rarely,  that  of  appendicitis.  They 
differ  from  the  abscess  of  Pott's  disease  in  that  they  are,  as  a  rule, 
acute  in  their  onset  and  are  accompanied  by  constitutional  symp- 
toms and  by  local  pain  and  sensitiveness.  In  such  cases  the 
motions  of  the  spine  may  be  restrained,  but  the  restraint  is  in 
great  degree  voluntary,  quite  different  from  the  rigidity  due  to 
disease  of  its  substance.  It  is  true  that  the  pelvic  abscess  of 
Pott's  disease  which  has  become  infected  may  cause  constitu- 
tional symptoms,  but  the  history  of  the  disability  and  discom- 
fort that  must  have  preceded  the  abscess,  together  with  the  prob- 
able presence  of  deformity,  will  make  the  diagnosis  clear.  Chronic 
abscess  in  the  pelvis  of  other  than  spinal  origin  may  be  the  result 
of  disease  of  the  pelvic  bones,  or  of  the  sacro-iliac  articulation, 
or  of  the  hip-joint.  It  may  be  caused  by  the  breaking  down  of 
retroperitoneal  lymph  glands,  or  it  may  have  its  origin  in  inflam- 
mation about  the  uterine  appendages,  and  cases  of  so-called 
idiopathic  inflammation  and  suppuration  of  the  iliopsoas  muscle 
have  been  described.  "In  childhood,  chronic  abscesses  in  this  local- 
ity are  almost  always  tuberculous  in  character,  and  are  caused  by 
disease  of  bone,  either  of  the  spine  or  of  the  pelvis.  Disease  of 
the  spine  can  be  determined  usually  by  the  methods  already  indi- 
cated, but  if  the  abscess  is  of  other  origin  its  exact  cause  can  be 


DIFFERENTIAL  DIAGNOSIS  47 

decided  in  many  instances  only  by  an  operative  exploration.  Ab- 
scesses of  this  character,  of  slow  and  apparently  painless  formation, 
may  finally  cause  a  swelling  in  the  inguinal  region  or  about  the 
saphenous  opening  that  in  the  adult  is  not  infrequently  mistaken 
for  hernia.  In  practically  all  cases,  however,  the  tumor  of  the 
abscess  may  be  made  out  on  palpation  within  the  pelvis,  and, 
although  the  contents  of  the  external  sac  may  be  in  part  forced 
back  into  the  larger  reservoir,  its  reduction  is  very  different  in 
feeling  from  that  of  a  true  hernia. 

Peculiarities  of  Lumbar  Pott's  Disease  in  Infancy.  —  Attention 
has  been  called  repeatedly  to  the  great  importance  of  careful 
observation  of  the  postures  and  movements  of  the  patient,  to 
the  change  in  the  contour  of  the  spine,  and  particularly  to  the 
abnormal  lordosis  and  peculiar  attitude  of  overerectness  in  the 
early  stage  of  disease.  But  the  description  of  attitudes  of  stand- 
ing and  walking,  and  of  the  contour  of  the  spine  which  is  the  result 
of  the  erect  posture,  does  not  apply  to  the  infant  in  arms,  nor  can 
the  spine  be  divided  into  contrasting  sections  for  the  purpose  of 
differential  diagnosis.  In  Pott's  disease  of  infancy  the  muscular' 
spasm  is  usually  more  intense  and  its  extent  is  greater;  the  child 
screams  when  it  is  moved  or  when  the  diapers  are  changed.  Slight 
irregularity  of  the  spinous  processes  indicating  the  position  of  the 
destructive  process  is  often  evident  and  abscess  is  not  unusual. 
There  is  usually  no  difficulty  in  determining  the  presence  of  disease 
even  in  very  early  cases,  but,  as  has  been  mentioned,  it  is  sometimes 
difficult  to  decide  whether  the  lumbar  spine  or  one  of  the  hip-joints 
is  involved. 

Pott's  disease  of  infancy  may  be  mistaken  for  acute  rhachitis,j 
or  scurvy.     The  symptoms  of  such  affections  are,  however,  not 
limited  to  the  spine,  but  involve  to  a  greater  or  less  degree  the 
limbs  and  joints,   indicating'  that  the  discomfort  and  pain  are 
due  to  a  general,  not  to  a  local,  disease.  • 

The  Rhachitic  Spine. — The  deformity  of  the  spine,  caused  by 
rhachitis,  is  not  infrequently  mistaken  for  that  of  Pott's  disease. 

It  has  been  stated  that  when  in  early  infancy  the  child  is  placed 
in  the  sitting  posture  the  spine  bends  in  a  long,  posterior  curve, 
indicative  of  the  weakness  normal  at  this  age.  Such  a  curvature 
is  characteristic  also  of  acquired  weakness  and  particularly  that 
caused  by  rhachitis  in  early  childhood.  The  weak  child  that  has 
never  walked  or  that  has  "  lost  its  walk"  sits  much  of  the  time  in 
its  chair,  or  is  carried  about  on  its  mother's  arms.  In  this  posture 
the  spine  is  habitually  bent  backward.  Soon  a  slight  projection 
persists,  even  when  the  child  is  lying  down.  This  usually  increases 
in  size  and  becomes  more  resistant,  forming  a  somewhat  rounded 
and  resistant  posterior  curvature  of  the  dorsolumbar  portion  of 
the  spine. 

The   diagnosis   from   Pott's   disease   should   be   made   without 


48  TUBERCULOUS  DISEASE  OF   THE  SPINE 

difficulty,  because  the  evidences  of  general  rhachitis  being  present, 
the  deformity  is  almost  as  much  to  be  expected  as  would  be  dis- 
tortions of  the  legs  were  the  child  walking.  If  the  patient  is  placed 
in  its  habitual  sitting  posture  it  will  be  seen  that  the  deformity  is 
simply  an  exaggeration  of  a  normal  attitude.  In  this  attitude  the 
patient  remains  contentedly  for  an  indefinite  time,  whereas  if 
Pott's  disease  were  present  the  child  would  lie  on  its  back  or  abdo- 
men. The  projection  is  rounded,  not  angular,  and  if  the  patient 
is  placed  in  the  prone  posture  the  projection  may  be  reduced,  in 
great  part,  by  raising  the  thighs  while  gentle  pressure  is  exerted 
upon  the  kyphosis.  Finally,  although  such  extension  and  pressure 
may  cause  discomfort,  there  is  complete  absence  of  the  muscular 
spasm  characteristic  of  Pott's  disease. 

It  may  be  stated,  then,  that  the  rhachitic  deformity  is  a  rounded 
curvature  of  the  lower  part  of  the  spine.  Its  cause  is  weakness 
and  habitual  posture.  The  rigidity  depends  upon  the  duration  of 
the  deformity.  The  pain,  if  the  rhachitis  is  acute,  is  general  and 
it  is  easily  explained  by  the  sensitive  condition  of  the  bones  and 
joints.  It  is  true  that  rhachitis  and  tuberculous  disease  of  the 
spine  may  be  combined,  but  in  such  rare  instances  the  symptoms 
of  the  more  serious  local  disease  will  make  themselves  evident  as 
distinct  from  those  of  the  general  weakness. 

Summary. — The  more  characteristic  symptoms  of  disease  of  the 
dorsolumbar  region  are : 

Increased  lordosis  or  overerectness  and  a  prominent  abdomen; 
a  cautious,  constrained,  or  waddling  gait;  less  often  a  lateral 
inclination  of  the  body  or  a  limp  caused  by  psoas  contraction. 

Stiffness  of  the  spine,  which  makes  bending  or  turning  the  body 
difficult. 

Pain  referred  to  the  back,  to  the  inguinal  region,  or  to  the  thighs, 
and  in  more  advanced  cases  the  characteristic  deformity. 

Disease  of  the  Thoracic  Region  of  the  Spine.  —  The  normal 
movement  of  this  section  of  the  spine,  which  includes  the  third 
and  tenth  vertebrae,  is  as  compared  with  those  above  and  below 
it,  slight;  thus,  disease  of  this  region  may  not  interfere  to  a  notice- 
able degree  with  the  general  functions  of  the  spine. 

As  this  part  of  the  column  curves  backward,  the  deformity, 
often  unattended  by  severe  symptoms,  is  not  infrequently  mis- 
taken for  round  shoulders  (Fig.  20).  It  seems  probable,  also, 
because  of  the  normal  backward  curve,  and  because  of  the  lever- 
age exerted  by  the  weight  of  the  head  and  arms,  that  deformity 
quickly  follows  disease.  At  all  events,  patients  are  not  often 
seen  before  it  is  present,  so  that  the  diagnosis  is  usually  evident 
on  inspection  of  the  patient. 

The  attitudes  are  not  especially  significant.  If  the  lower  part 
of  the  region  is  involved,  and  if  the  disease  is  at  all  acute,  they 
are  similar  to  those  of  disease  of  the  lower  region,  viz.,  erectness, 


DISEASE  OF  THE  THORACIC  REGION  OF  THE  SPINE     49 

the  peculiar,   cautious,   in-toeing  step,   and  the  disincUnation  to 
bend  the  body  forward  (Fig.  19). 

If,  on  the  other  hand,  the  upper  part  is  affected,  the  attitude 
is  often,  particularly  in  young  children,  one  of  weakness;  there 
is  a  slight  forward  inclination  of  the  body,  the  head  being  tilted 
backward  or  inclined  toward  one  side,  and  a  peculiar  shrugging, 
squareness,    and   elevation   of  the   shoulders   is   often   noticeable 


Fig.  20. — Pott's  disease  of  the  middle 
dorsal  region  at  an  early  stage,  showing 
slight  increase  of  the  dorsal   kyphosis,  Fig.  21. — Disease  of  the  upper  dorsal 

without  noticeable  change  in  the  atti-  region.  Characteristic  attitude, 

tude.     Contrast  with  Fig.  21. 

(Fig.  21).  In  many  instances  the  apparent  elevation  of  the  shoul- 
ders is  in  reality  caused  by  the  deformity,  which  shortens  the  neck 
and  lowers  the  head  (Fig.  23). 

In  this  connection  it  should  be  mentioned  that  one  of  the  second- 
ary effects  of  the  disease,  the  so-called  pigeon  chest,  may  first  attract 
the  attention  of  the  parent.     The  forward  inclination  of  the  spine 
causes  a  flattening  of  the  upper  part  of  the  chest,  while  the  sternum 
4 


50  TUBERCULOUS  DISEASE  OF   THE  SPINE 

sinks  dowmvard  and  becomes  prominent;  thus  the  anteropos- 
terior diameter  of  the  thorax  is  increased,  and  it  is  compressed  from 
side  to  side,  resembhng  very  closely  the  deformity  of  rhachitis. 
As  the  pigeon  chest  of  Pott's  disease  is  always  secondary  to  the 
spinal  deformity,  its  cause,  of  course,  becomes  apparent  on  examin- 
ing the  back. 

Of  the  early  symptoms  of  disease  of  the  thoracic  region,  pain 
and  labored  or  "grunting"  respiration  are  the  most  characteristic. 
Pain  referred  to  the  abdomen  and  to  the  front  and  sides  of  the  chest 
is  usually  an  early  and  often  a  constant  symptom;  thus  persistent 
"stomach-ache"  in  a  child  should  always  lead  to  an  examination 
of  the  spine.  A  "spasm  of  pain"  is  sometimes  excited  by  lateral 
compression  of  the  chest,  as  when  the  child  is  lifted  suddenly  by 
the  parent. 

Of  much  greater  importance,  however,  is  the  labored  or  grunting 
respiration,  which,  indeed,  is  almost  pathognomonic  of  Pott's  dis- 
ease. This  "grunting"  is  caused  by  the  interference  with  respira- 
tion, more  particularly  with  the  normal  rhythmical  movements 
of  the  ribs.  The  restraint  is,  in  part,  due  to  muscular  spasm  and 
to  deformity  and  in  part  to  the  voluntary  effort  of  the  patient.  The 
inspiration  is  quick  and  shallow,  in  great  degree  diaphragmatic, 
and  expiration  is  accompanied  by  a  sigh  or  grunt.  This  is  caused 
apparently  by  a  momentary  closure  of  the  larynx  to  resist  the  escape 
of  air  and  thus  sudden  motion  of  the  chest  walls.  Grunting  respira- 
tion is,  of  course,  an  evidence  of  the  more  acute  t^'pe  of  disease, 
but  even  in  mild  cases  will  be  noticed  when  the  patient  is  fatigued  or 
during  play. 

An  aimless  cough  may  be  sjonptomatic  of  disease  of  the  upper 
dorsal  region,  and  spasmodic  attacks  resembling  asthma  are  not 
uncommon. 

In  most  instances  the  characteristic  deformity  is  present  on 
examination,  and  in  the  exceptional  cases  in  which  it  is  absent 
a  slight  change  in  contour  will  be  apparent  w^hen  the  trunk  is  flexed. 
In  place  of  the  long,  regular  curve  of  the  normal  spine  a  point  where 
two  distinct  outlines  unite  will  be  observed — one  of  which  may  be 
curved,  while  the  other  is  practically  straight  (Fig.  7). 

^Muscular  spasm  appears  on  sudden  movement  of  the  spine,  and 
it  may  be  demonstrated  in  children  by  raising  the  legs  and  swaying 
the  body  from  side  to  side  (Fig.  15).  The  change  in  the  rhythm 
of  respiration  has  been  mentioned.  Although  the  respiratory 
movement  of  the  entire  thorax  is  lessened  in  range,  the  restraint 
does  not  affect  all  the  ribs  equally;  those  that  articulate  with  the 
diseased  vertebrae  are  often  nearly  motionless,  while  the  move- 
ment of  those  at  a  distance  from  the  disease  may  approach  the 
normal. 

In  tracing  the  neuralgic  pain  to  its  source  the  sharp,  downward 
inclination  of  the  ribs  must  be  borne  in  mind;   thus  the  cause  of 


DISEASE  OF  THE  THORACIC  REGION  OF  THE  SPINE     51 


pain  in  the  "stomach"  must  be  looked  for  between  the  shoulder- 
blades. 

As  in  the  lumbar  region,  slight  lateral  deviation  of  the  spine  is  not 
uncommon,  and  it  may  be  accompanied  by  a  noticeable  twist 
or  rotation  so  that  the  ribs  on  one  side  project  slightly  backward 
(Fig.  22). 

In  this  region  the  sjyinal  cord  is  more  often  involved  than  in 
disease  of  other  sections;  thus  an  awkward,  stumbling  gait  and 
finally  "loss  of  walk"  may  first  attract 
attention.  The  paralysis  of  Pott's  dis- 
ease and  its  differential  diagnosis  are 
considered  in  more  detail  elsewhere. 

Abscess  as  a  complication  of  disease 
of  the  thoj'acic  region  cannot  be  demon- 
strated by  palpation  unless  it  has  found 
an  outlet  between  the  ribs,  but  percus- 
sion will  often  show  an  area  of  dulness 
or  flatness  extending  from  the  diseased 
vertebrae  toward  the  lateral  aspect  of  the 
chest.  This  is  due  in  part,  however,  to 
the  inflammatory  thickening  of  the  tis- 
sues in  the  neighborhood.  In  rare 
instances  the  abscess  may  press  directly 
upon  the  trachea  or  bronchi  and  cause 
spasmodic  attacks  of  dyspnea  resem- 
bling asthma. 

Diagnosis. — It  is  hardly  necessary  to 
mention  the  list  of  affections  that  may 
cause  pain  in  the  chest  or  abdomen;  it 
is  sufficient  to  state  that  such  symptoms 
always  require  a  physical  examination. 
The  same  statement  applies  to  irregular 
respiration,  to  cough,  and  to  so-called 
asthma. 

Occasionally  tuberculous  disease  of 
the  thoracic  section  in  adolescence  is 
practically  painless,  and  the  resulting 
deformity  is  rather  rounded  than  angu- 
lar, so  that  it  may  be  mistaken  for 
round  shoulders.  "Round  shotdders" 
is,  however,  as  a  rule,  of  long  dura- 
tion. The  exciting  cause  or  causes  of  postural  deformity  in  occu- 
pation or  otherwise  are  indicated  often  by  the  history.  The 
rigidity  is  less  marked  than  in  Pott's  disease,  and  neuralgic  pain 
is  absent. 

The  contour  of  the  rhachitic  kyphosis  has  been  described.  It 
should  be  evident  that  a  more  or  less  angular  projection  in  the 


Fig.  22.  —  Marked  lateral 
deviation  of  the  spine  with 
rotation.  Deformity  at  the 
eighth  dorsal  vertebra. 


52 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


upper  part  of  the  spine  could  not  be  rhachitic;  and  yet  because 
of  the  absence  of  pain  this  diagnosis  is  made  not  infrequently, 
and  as  a  consequence  the  activity  of  the  tuberculous  disease  may 
be  increased  by  massage  and  exercises. 

Lateral  deviation  of  the  spine  as  a  symptom  of  disease  hardly 
could  be  mistaken  for  the  ordinary"  rotary-lateral  curvature,  in  which 
pain  and  muscular  rigidity  are  absent. 


Fig.  23. — Double  psoas  contraction  of  an  extreme^degree  and  paralysis.     The  arms 

used  asjsupports. 

■  Acute  affections  within  the  chest,  pleurisy,  pneumonia,  and 
.empyema,  are  sometimes  accompanied  by  lateral  deviation  of 
the  spine,  but  the  sudden  onset  and  the  constitutional  and  local 
symptoms  that  accompany  such  affections  should  make  the  cause 
of  the  deformity  and  pain  evident.  It  is  because  these  cases  are 
sometimes  sent  to  orthopedic  clinics  for  braces  that  they  seem 
worthy  of  mention. 

The  abscesses  in  this  region,  as  has  been  mentioned,  cause  usually 
dulness  or  flatness  on  percussion  of  the  chest,  and  within  this 
area  friction  sounds  and  rales  may  be  heard.  The  tuberculous 
fluid  may  remain  indefinitely  in  the  posterior  mediastinum  and 


DISEASE  OF  THE  UPPER  REGION  OF  THE  SPINE        53 

the  area  of  flatness  may  extend  beyond  the  axillary  line,  yet  it  may 
give  rise  to  no  symptoms.  If  the  diagnosis  of  Pott's  disease  had  not 
been  made  or  if  the  presence  of  the  abscess  had  not  been  determined 
by  the  previous  physical  examination,  it  might  be  mistaken,  during 
an  acute  exacerbation  of  the  disease  or  constitutional  disturbance 
from  other  cause,  for  pleurisy  or  empyema  or  even  for  phthisis. 
In  all  cases,  therefore,  a  careful  examination  of  the  chest  should  be 
made  from  time  to  time  in  order  that  the  presence  or  absence  of 
abscess  may  be  recorded.  n ;_ 

Summary. — Pott's  disease  of  the  thoracic  region  is  often  insidious 
in  its  onset,  causing  no  positive  symptoms  before  the  *stage  of 
deformity. 

Its  most  characteristic  symptoms  are  pain  referred  to  the  front 
and  sides  of  the  body  and  the  grunting  respiration. 

If  the  disease  is  progressive,  weakness  and  stiffness  are  present. 
The  attitude,  when  the  disease  is  in  the  lower  thoracic  region, 
resembles  that  of  lumbar  disease;  if  the  upper  part  is  affected  the 
head  is  tilted  somewhat  backward  and  the  shoulders  appear  to 
be  elevated. 

2.  Disease  of  the  Upper  Region.  —  The  upper  region  of  the 
spine,  which  includes  the  cervical  and  two  of  the  dorsal  vertebrae, 
corresponds  in  freedom  of  movement  and  in  its  contour  to  the 
lumbar  region.  From  the  functional  stand-point  it  may  be  divided 
into  two  parts.  Of  these  the  superior  or  occipito-axoid  section  is 
peculiar  in  that  it  contains  no  vertebral  body  or  intervertebral 
cartilage,  and  in  that  the  movements  of  the  head  are  carried  out 
in  special  joints  and  are  controlled  by  special  muscles.  Occipito- 
axoid  disease  is  relatively  more  frequent  in  adult  life  than  in 
childhood  and  it  is  as  compared  to  disease  of  other  regions  of  the 
spine  more  dangerous  because  of  the  proximity  of  the  vital  centres 
which  may  be  injured  by  pressure  or  by  sudden  displacement  of 
the  weakened  vertebrae. 

Symptoms. — In  a  typical  case  the  symptoms  are  neuralgic  pain 
radiating  over  the  back  and  sides  of  the  head,  following  the  dis- 
tribution of  the  auricular  and  occipital  nerves.  The  neck  is  stiff 
and  the  head  may  be  fixed  in  the  median  line,  the  chin  being  some- 
what depressed;  or  more  often  it  is  tilted  to  one  side,  simulating 
the  attitude  of  torticollis  (Fig.  24). 

The  attitude  and  aypearance  of  the  patient,  when  normal  move- 
ment of  the  neck  is  restrained  by  a  painful  disease,  is  character- 
istic ;  the  eyes  follow  one,  or  the  body  is  turned,  when  the  attention 
of  the  patient  is  attracted.  The  patient  moves  carefully,  in  order 
to  avoid  jar;  often  the  chin  is  instinctively  supported  by  the  hand, 
and  a  favorite  attitude  is  one  in  which  the  patient  sits  with  elbows 
on  the  table,  the  hands  supporting  the  head  (Fig.  25).  If  the 
attempt  is  made  to  raise  the  chin,  or  to  rotate  the  head,  the  patient 
seizes  the  hands  of  the  examiner,  and,  it  may  be,  screams  in  appre- 


54 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


hension.  There  may  be  slight  bulging  or  infiltration  of  the  tissues 
about  the  seat  of  disease.  The  affected  vertebrse  are  usually  sensitive 
to  direct  pressure,  and  not  infrequently  deep  fluctuation  in  the 
suboccipital  triangle  can  be  made  out. 

The  atlo-axoid  junction  lies  just  behind  the  posterior  wall  of 
the  pharynx,  on  a  line  with  the  upper  teeth.  Here  abscess  may 
appear  early  in  the  course  of  the  disease,  causing  s^Tnptoms  of 
obstruction,  such  as  snoring,  change  in  the  quality  of  the  voice, 
difficulty  in  swallowing,  or  spasmodic  attacks  of  so-called  croup. 


Fig.  24. — Ce^^•ical  disease  with  abscess.     Characteristic  attitude. 


If  abscess  is  present  or  if  the  disease  is  at  all  acute,  the  reclining 
posture  sometimes  aggravates  the  symptoms,  so  that  "getting 
the  child  to  bed"  is  often  a  tedious  and  difficult  task. 

In  certain  instances  the  location  of  the  disease  whether  of  the 
occipito-atloid  or  of  the  atlo-axoid  articulation,  may  be  deter- 
mined, but,  as  both  joints  are  to  a  great  extent  controlled  by  the 
same  muscles,  this  is  often  impossible. 

The  uppermost  joint,  that  between  the  atlas  and  occiput,  per- 
mits the  nodding  movement  of  the  head,  or  flexion  and  extension 
on  the  spine,  the  range  being  about  50  degrees,  20  degrees  forward 


DISEASE  OF  THE   UPPER  REGION  OF  THE  SPINE        55 

and  30  degrees  backward,  while  the  atlo-axoid  joint  permits  rotation 
of  the  atlas  about  the  axis  through  a  range  of  about  60  degrees. 

If  the  disease  be  in  the  upper  joint  the  nodding  movements 
should  be  more  restricted  than  those  of  rotation,  and  vica  versa.  To 
make  the  test  one  must  grasp  the  neck  firmly  in  order  to  restrain 
movement  except  in  the  joint  under  examination.  Because  of 
free  motion  in  the  cervical  region  fixation  of  the  upper  articulations 
is  often  overlooked  when  the  disease  is  of  the  subacute  type. 


Fig.  25. — Cervical  disease.     A  characteristic  attitude. 

The  Lower  Cervical  Region. — The  symptoms  of  disease  of  the 
lower  cervical  section,  although  similar  in  character,  are  often 
less  marked  than  those  of  the  upper  region.  The  cervical  spine 
becomes  straighter,  and  often  a  slight  backward  projection  or 
thickening  indicates  the  position  of  the  disease.  The  head  is 
usually  turned  to  one  side  by  contraction  of  the  lateral  muscles 
in  an  attitude  of  wry-neck  (Fig.  26).  The  pain  is  referred  to  the 
neck,  to  the  sternal  region,  or  down  the  arms,  following  the  dis- 
tribution of  the  brachial  plexus. 

In  the  more  advanced  cases  one's  attention  may  be  attracted 
to  the  cervical  region,  because  the  neck  seems  short  and  because 


56 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


the  head  is  tiked  backward.  The  entire  back  shows  a  compen- 
satory flattening,  yet  no  deformity  is  apparent  until  the  occiput 
is  raised  and  drawn  forward,  when  a  shelf-hke  projection  may 
be  feh  at  what  appears  to  be  the  extremity  of  the  spine,  but  which 
is  reahy  an  angular  deformity  at  the  third  or  fourth  vertebra. 

This  emphasizes  the  importance  of  careful  observation  of  the 
contour  of  the  spine,  and  the  necessity  of  explaining  to  oneself 
every  change  from  the  normal  that  may  be  noticed. 

Disease  at  the  cervicodorsal  junction  resembles  in  its  symptoms 
that  of  the  upper  dorsal  region.  The  head  is  usually  tilted  back- 
ward (Fig.  21)  or  it  may  be  turned 
to  one  side.  Disease  at  this  point 
is  often  subacute  in  character,  and 
paralysis  from  implication  of  the 
spinal  cord  sometimes  appears  be- 
fore deformity  is  apparent.  Occa- 
sionally irregularity  of  the  pupils 
is  present  because  of  sympathetic 
involvement. 

The  spinous  process  of  the 
seventh  cervical  or  first  dorsal 
vertebra  is  often  prominent  (verte- 
bra prominens)  in  normal  indi- 
viduals, and  it  may  be  mistaken 
for  the  deformity  of  disease,  espe- 
cially when  pain  is  referred  to 
this  region,  as  in  hysterical  or 
hyperesthetic  subjects.  If  such 
projection  is  symptomatic  of  dis- 
ease there  is  almost  always  a  slight 
compensatory  flattening  of  the  spine  below  the  point  and  a  certain 
degree  of  rigidity  of  the  surrounding  muscles. 

Diagnosis. — ^As  stift"ness  and  distortion  of  the  neck  are  the  most 
prominent  symptoms  of  disease  of  this  region,  one  must  consider 
first  the  forms  of  torticollis  for  which  it  might  be  mistaken.  In 
typical  torticollis  the  distortion  of  the  head  is  caused  almost  invari- 
ably by  contraction  of  the  muscles  supplied  in  part  by  the  spinal 
accessory  nerve,  the  sternomastoid,  and  trapezius,  thus,  the  chin 
is  slightly  elevated  and  turned  away  from  the  contracted  muscle. 

Congenital  torticollis,  which  has  existed  from  birth,  is  not  accom- 
panied by  pain  and  it  could  hardly  be  mistaken  for  a  symptom  of 
disease. 

Acute  ''  rheumatic'^  torticollis,  "stift'  neck,"  is  a  common  aft'ection. 
It  is  of  sudden  onset,  "'in  a  single  night;"  the  affected  muscles  are 
sensitive  to  pressure;  the  course  of  the  aft'ection  is  short  and  it  is 
of  comparative  insignificance. 

A  more  persistent  form  of  acute  torticollis,  characterized  by  mus- 


FiG.    26.  —  Disease   of   the  middle 
cervical  region  at  an  early  stage. 


DISEASE  OF  THE   UPPER  REGION  OF  THE  SPINE        57 

cular  spasm  and  by  local  sensitiveness,  sometimes  accompanies  en- 
larged or  suppurating  cervical  glands;  it  may  follow  "earache,"  "ton- 
sillitis," "sore  throat,"  or  any  form  of  irritation  about  the  pharynx. 
This  form  of  wry-neck  is  not  only  very  painful,  but  it  may  persist 
indefinitely,  and  permanent  deformity  may  result.  The  onset  is 
usually  sudden;  the  pain  and  sensitiveness  are  local  and  are  con- 
fined, as  a  rule,  to  the  contracted  part.  The  sternomastoid  and 
trapezius  muscles  are  most  often  involved;  thus,  the  wry-neck  is 
typical.  If  the  tension  be  relaxed  by  inclining  the  head  toward  the 
contracted  muscles,  motion  of  the  spine  itself  will  be  found  to  be 
free  and  painless;  but  if  traction  is  made  on  the  contracted  muscles 
it  causes  discomfort,  and  it  is  usually  resisted  by  the  patient. 


Fig.  27. — -Deformity  at  the  cervical  vertebra  indicated  by  the  wrinkle  in  the  neck. 
The  attitude  of  the  head  and  the  compensatory  projection  in  the  lumbar  region  are 
characteristic. 


In  disease  of  the  occipito-axoid  region  the  distortion  of  the  head 
is  by  no  means  typical  of  sternomastoid  contraction;  it  may  be 
tilted  up  or  down  or  laterally  to  an  exaggerated  degree.  In  other 
words,  the  wry-neck  of  Pott's  disease  is  an  irregular  distortion, 
because  it  is  not  dependent  on  the  contraction  of  a  particular  muscle 
or  muscular  group.  "  In  torticollis  the  chin  is  turned  away  from  the 
contracted  muscle,  while  in  Pott's  disease  it  is  turned  toward  the 
contracted  muscle."  This  is  an  axiomatic  expression  of  the  fact 
that  the  distortion  of  the  head  symptomatic  of  atlo-axoid  disease 
depends,  in  great  degree,  upon  the  spasm  of  the  small  muscles  that 


58  TUBERCULOUS  DISEASE  OF   THE  SPINE 

directly  control  these  joints,  the  recti  and  obliqui,  not  upon  the 
contraction  of  the  sternomastoid  muscle,  as  in  the  ordinary  form  of 
wry-neck.  Again,  the  contraction,  symptomatic  of  Pott's  disease, 
of  this  or  other  regions,  is  the  result  of  muscular  spasm  that  checks 
painful  motion.  If  the  head  be  grasped  firmly  by  the  hands  and 
if  gentle  traction  is  made,  the  distortion  may  often  be  overcome 
without  discomfort  to  the  patient.  If  similar  traction  is  made  upon 
the  contracted  muscles  of  acute  wry-neck  the  pain  is  increased  and 
the  patient  protests. 

In  disease  of  the  middle  cervical  region,  however,  the  distor- 
tion may  resemble  closely  that  of  acute  torticollis;  for  if  the  latter 
is  caused  by  the  irritation  of  inflamed  or  suppurating  glands  there 
is  often  sensitiveness  to  manipulation,  with  more  or  less  general 
muscular  spasm.  In  such  cases  the  diagnosis  may  be  impossible 
until  apparatus  has  been  applied  to  rest  the  part  and  to  correct 
the  deformity. 

As  has  been  stated,  the  head  may  be  tilted  backward  to  com- 
pensate for  deformity  in  the  middle  cervical  region,  and  in  some 
instances  it  may  be  drawn  backward  by  spasm  of  the  posterior 
muscles.  Such  a  case  might  be  mistaken  for  cervical  opisthotonos,  or 
posterior  torticollis,  which  is  sometimes  seen  in  young  infants 
suffering  from  exhausting  diseases,  basilar  meningitis,  and  the  like. 
In  such  conditions,  however,  the  characteristic  symptoms  of  Pott's 
disease  are,  of  course,  absent. 

The  opposite  attitude,  viz.,  a  forward  droop  of  the  head  due  to 
weakness  of  the  trapezii  muscles,  is  not  uncommon  as  a  sequence 
of  diphtheria  or  other  forms  of  contagious  disease.  (1)  In  a  series 
of  1313  cases  of  diphtheria  6  per  cent,  were  paralyz,ed;  of  these  77 
per  cent,  recovered.  In  two-thirds  of  the  cases  the  soft  palate  was 
alone  involved.^  This  droop  may  be  accompanied,  also,  by  con- 
traction of  one  of  the  sternomastoid  muscles  and  by  pain.  In  such 
cases  the  history  of  the  preceding  affection,  the  weakness  or  paralysis 
of  other  parts,  as  of  the  soft  palate,  of  accommodation  of  the  eyes 
and  the  like,  together  with  the  general  bodily  weakness  should 
make  the  diagnosis  clear. 

Injury  of  the  upper  segment  of  the  spine,  strain,  contusion, 
or  fracture,  unless  efficiently  treated,  may  cause  symptoms  re- 
sembling very  closely  those  of  tuberculous  disease;  for  example, 
pain,  radiating  over  the  back  of  the  head,  rigidity  and  deformity 
of  the  neck,  and  even  infiltration  and  local  tenderness  about  thp 
injured  part.  Such  cases,  when  seen  several  weeks  or  months  after 
the  accident,  are  puzzling,  because  one  may  be  in  doubt  whether 
the  symptoms  were  caused  by  a  simple  injury  or  whether  tuber- 
culous infection  may  have  followed  or  preceded  it.  In  such  cases 
a  positive  diagnosis  cannot  be  made  until  the  effect  of  rest  and  pro- 

1  A.   Love:  Glasgow   Med.   Jour.,   October,    1911. 


DISEASE  OF  THE  UPPER  REGION  OF  THE  SPINE         59 

tection  has  been  observed — ^that  is  to  say,  suspicious  cases  should 
be  treated  as  one  would  treat  actual  disease.  If  the  case  is  simply 
one  of  injury,  recovery  may  be  rapid  and  complete,  while  if  disease 
is  present  the  symptoms  only  will  be  relieved. 

The  occipito-axoid  articulations  may  be  involved  in  acute  or 
chronic  arthritis  and  the  like.  If  the  manifestations  are  general 
in  character  the  diagnosis  is,  of  course,  easily  made;  but  occa- 
sionally the  infection  is  limited  to  the  joints  at  the  upper  extremity 
of  the  spine  and  it  may  be  attended  by  fever  and  constitutional 
disturbance.  The  sudden  onset  and  rapid  recovery  if  proper 
treatment  is  applied  are  the  diagnostic  points. 

Abscess  in  the  cervical  region  is  a  secondary  symptom,  and 
although  the  change  in  the  voice  and  the  difficulty  in  breathing 
or  swallowing  may  be  the  most  noticeable  symptoms,  yet  they 
are  always  accompanied  by  some  of  the  characteristic  signs  of 
Pott's  disease.  Whenever  the  diagnosis  of  cervical  disease  is 
made  one  should  examine  the  throat,  and  whenever  a  chronic 
retropharyngeal  abscess  is  present  one  should  look  for  the  symp- 
toms of  Pott's  disease.  The  diagnosis  of  the  retropharyngeal 
abscess  can  be  made  only  by  inspection  and  palpation;  therefore 
one  need  only  mention  the  fact  that  symptoms  of  obstruction  in 
the  throat,  similar  to  those  of  abscess,  may  be  caused  by  adenoid 
growths  and  by  enlarged  tonsils. 

Retropharyngeal  abscess  by  no  means  always  indicates  Pott's 
disease.  It  may  be  one  of  the  sequelae  of  contagious  disease  or 
a  complication  of  pharyngitis.  It  is  then  rapid  in  its  onset  and 
is  not  accompanied  by  the  symptoms  of  Pott's  disease. 

Summary.— If  the  disease  is  of  the  upper  or  occipito-axoid  region 
the  head  is  usually  fixed  in  an  attitude  of  deformity,  which  may  be 
slight  or  extreme.  If  the  disease  is  of  the  middle  region,  the  atti- 
tude more  often  resembles  that  of  ordinary  torticollis.  In  the  lower 
region  marked  spasm  of  muscles  is  unusual,  but  the  head  inclines 
backward  or  toward  one  shoulder. 

The  contour  of  the  cervical  spine  changes  as  the  disease  pro- 
gresses; the  normal  anterior  curvature  is  obliterated;  thus,  the 
head  is  pushed  forward,  while  the  dorsal  section  of  the  spine  be- 
comes flat  or  even  incurvated  in  compensation.  The  seat  of  the 
disease  is  often  shown  by  an  area  of  thickening  or  local  sensitive- 
ness to  deep  pressure. 

J  Diagnosis  in  General.  —  Weakness  and  the  so-called  "loss  of 
walk"  are  well-known  symptoms  of  Pott's  disease,  and  on  this 
account  children  suft'ering  from  various  types  of  weakness  or 
paralysis  are  often  brought  to  orthopedic  clinics  for  the  treat- 
ment of  "spine  disease." 

Certain  forms  of  paralysis  bear  a  superficial  resemblance  to 
some  of  the  symptoms  of  Pott's  disease;  for  example,  pseudo- 
hypertrophic muscular  dystrophy  to  the  attitude  caused  by  disease 


60  TUBERCULOUS  DISEASE  OF   THE  SPINE 

of  the  lumbar  region,  and  diphtheritic  paralysis  to  that  of  the  dorsal 
region.  Spastic  paralysis,  of  cerebral  origin,  resembles  somewhat 
the  paralysis  of  Pott's  disease,  but  it  may  be  differentiated  by  the 
absence  of  pain  by  the  history,  and  by  what  is  apparent  in  most 
cases,  the  mental  impau*ment. 

Primary  spastic  spinal  paraplegia  resembles  the  paralysis  of 
Pott's  disease  more  closely,  but  the  essential  symptoms  of  a  de- 
structive disease  of  the  spine  are  absent.  The  contractions  com- 
bined with  the  weakness  and  pain  that  sometimes  follow  cerebro- 
spinal meningitis  may  be  mistaken  for  the  s^^nptoms  of  bone 
disease,  but  they  are  readily  explained  by  the  history  of  the  case. 

Forms  of  organic  disease  of  the  spine  other  than  tuberculosis 
as,  for  example,  malignant  disease,  syphilis,  spondylitis  deformans 
and  the  like  in  which  the  question  in  differential  diagnosis  is  not 
of  the  presence  or  absence  of  disease  but  rather  of  its  nature  are 
described  in  Chapter  II. 

The  list  of  affections  that  has  been  considered  in  the  differ- 
ential diagnosis  is  a  long  one,  but  it  has  been  made  up  from  actual 
experience.  Mistakes  in  diagnosis  must  be  accounted  for  usually 
by  carelessness  or  ignorance,  or  because  of  insufficient  opportunity 
for  examination;  but  in  the  earliest  stages  of  the  disease  repeated 
examinations  and  even  tentative  treatment  may  be  necessary  before 
the  diagnosis  is  assured. 

The  Roentgen-ray  Photography  as  a  Means  of  Diagnosis. — Roent- 
gen pictures  are  of  comparatively  little  importance  from  the  stand- 
point of  diagnosis  in  early  childhood  because  the  symptoms 
usually  precede  the  destructive  changes  in  the  bone.  They  are  of 
value  as  a  means  of  determining  the  exact  extent  of  the  disease. 
If  the  negative  is  well-defined,  the  diseased  vertebra?  are  seen  to 
be  irregular  in  outline,  or  they  may  be  lost  in  a  peculiar  bhu".  By 
counting  from  above  and  below  the  boundaries  of  the  disease  may  be 
made  out,  but  inferences  as  to  its  character  and  quality  must  be 
made  from  the  rational  and  physical  signs  (Fig.  35).  The  tuber- 
culin test  is  considered  in  Chapter  Y. 

The  Record  of  the  Case. — The  history  and  the  results  of  the 
examination  of  the  patient  should  be  recorded  somewhat  in  the 
following  order: 

1.  The  family  and  the  personal  history. 

2.  The  history  of  the  disease,  with  especial  reference  to  its 
mode  of  onset,  its  probable  duration,  to  the  noticeable  s^iiiptoms, 
and  to  previous  treatment. 

3.  The  physical  examination.  This  should  include  the  gen- 
eral condition  of  the  patient,  the  height  and  weight,  the  attitude, 
the  character  of  the  disease,  whether  progressive,  as  indicated 
by  muscular  spasm  and  pain  on  motion,  or  quiescent,  the  pres- 
ence of  abscess  or  paralysis  as  a  complication,  and,  finally,  the 
position  and  extent  of  the  disease.     This  is  best  shown  by  a  trac- 


TREATMENT 


61 


ing  made  by  means  of  a  strip  of  lead  or  pure  tin,  of  such  thickness 
that  it  may  be  readily  molded  on  the  spine  and  yet  hold  its  shape 
when  removed  (Fig.  28). 

The  tracing  should  be  of  the  entire  spine,  made  while  the  patient 
lies  extended  in  the  prone  position,  and  the  exact  location  of  the 
most  prominent  spinous  process  should  be  marked  upon  it.  In 
determining  the  position  of  the  disease  it  is  well  to  count  the  spinous 
processes  from  below  upward,  beginning  with  that  of  the  fourth 
lumb.ar  vertebra,  which  lies  on  a  line  drawn  between  the  highest 
points  of  the  iliac  crests.  There  are  other  landmarks  that  are 
approximately  correct.  Sometimes  the  last  rib  may  be  traced  to 
its  origin;  the  scapula  covers  the  second  and  seventh  ribs,  the  root 
of  the  spine  of  the  scapula  and  the  middle  point  of  the  glenoid 
cavity  being  "bn  a  line  with  the  third,  and  its  inferior  angle  oppo- 
site the  tip  of  the  seventh  dorsal  spinous  process.  The  upper 
margin  of  the  sternum  is  opposite  the  interval  between  the  second 


Fig.  28. — Tracings  of  the  spine,  illustrating  recession  of  deformity  under  treatment 

by  the  convex  frame. 


and  third  dorsal  vertebree.  In  many  instances  the  vertebra  prom- 
inens  and  the  spinous  process  of  the  axis  can  be  identified.  Such 
landmarks  are,  of  course,  somewhat  displaced  if  the  deformity  is 
extreme,  but  they  are  always  sufficiently  correct  to  check  errors 
in  counting  the  spinous  processes. 

The  history  furnishes  a  foundation  on  which  treatment  is  con- 
ducted and  from  which  its  results  may  be  determined.  It  should 
present,  therefore,  the  condition  of  the  patient  when  treatment 
is  begun,  and  in  it  the  complications  and  incidents  and  the  changes 
in  the  treatment  should  be  noted  at  regular  intervals  while  the 
patient  is  under  observation. 

Treatment. — The  general  treatment  of  tuberculous  disease  is 
considered  in  Chapter  V.  Pott's  disease  is  the  most  serious  of 
the  tuberculous  aft'ections  of  the  bones,  and  the  importance  of 
hygienic  surroundings,  nourishing  food,  sunlight,  and,  above  all, 
open  air  both  day  and  night,  if  possible,  can  hardly  be  exaggerated. 

The  General  Principles  of  Mechanical  Treatment. — Under  normal 
conditions  the  weight  of  the  head  and  of  the  thoracic  and  abdomi- 
nal organs  tends  to  bend  the  spine  forward  and  downward — a 


62  TUBERCULOUS  DISEASE  OF   THE  SPINE 

tendency  that  is  resisted  by  the  action  of  the  muscles  of  the  back. 
If  the  resistance  is  weakened,  as  in  Pott's  disease  by  the  direct 
destruction  of  the  weight-bearing  portion  of  the  spine,  this  tend- 
ency toward  deformity  is,  of  course,  greatly  increased.  Thus  the 
pressure  of  the  superincumbent  weight  upon  the  weakened,  part 
and  the  strain  of  motion  are,  from  the  mechanical  stand-point,  the 
most  important  factors  in  the  production  of  deformity. 

When  the  trunk  is  bent  forward,  the  intervertebral  disks  are 
compressed  and  the  pressure  upon  the  vertebral  bodies  is  increased. 
When  it  is  held  erect  or  is  bent  backward  this  pressure  is  lessened, 
and  a  part  of  the  weight  is  transferred  to  the  articular  processes 
and  to  the  posterior  parts  of  the  column.  The  object  of  a  brace 
or  other  support  is  to  hold  the  spine  in  the  extended  position,  so 
that  pressure  on  the  diseased  vertebrae  may  be  removed.  One 
aims  to  splint  the  spine  as  effectively  as  if  it  were  broken,  in  order 
to  relieve  the  discomfort  and  pain,  so  depressing  to  the  patient,  and 
to  secure  the  rest  that  is  essential  to  repair. 

The  effectiveness  of  a  particular  splint  or  support,  whether 
applied  to  a  broken  bone  or  to  a  diseased  spine,  depends  upon 
the  area  that  it  covers  on  either  side  of  the  part  to  be  supported 
and  upon  the  accuracy  of  its  adjustment,  as  well  as  upon  the 
damage  that  the  part  has  already  sustained,  and  the  strain  to  which 
it  still  may  be  subjected. 

From  this  stand-point  it  is  evident  that  it  is  difficult  to  apply 
effective  support  to  the  trunk  because  of  its  size,  shape,  and  con- 
tents, and  it  is  apparent  also  that  the  mechanical  conditions  are 
more  favorable  in  some  parts  than  in  others.  For  example,  the 
splint  should  be  effective  when  the  disease  is  of  the  lower  dorsal 
region,  because  its  two  extremities,  attached  to  the  pelvis  and  to 
the  shoulders,  are  equidistant  from  the  point  to  be  supported. 
The  conditions  are  unfavorable  in  disease  of  the  upper  thoracic 
region,  because  the  weight  of  the  head  and  of  the  arms  tends  to 
increase  the  deformity,  and  because  of  the  insufficient  leverage 
that  can  be  secured  for  the  supporting  appliance.  The  pelvis  is 
the  base  of  support  for  all  forms  of  splints,  and  if  it  is  smaller  than 
the  abdomen,  as  in  infancy,  ambulatory  appliances  are  far  less 
effective  than  in  older  subjects. 

In  actual  practice  the  treatment  of  Pott's  disease  is  influenced 
by  the  age  of  the  patient,  the  situation  of  the  disease,  the  dura- 
tion of  the  deformity,  and  by  many  other  circumstances,  but 
the  relative  efficiency  of  braces  or  other  appliances  may  be  de- 
cided on  purely  mechanical  grounds.  Thus,  as  the  ultimate 
deformity  of  Pott's  disease  is,  in  great  degree,  caused  by  the  force 
of  gravity  acting  on  a  iveakened  spine,  the  most  effective  treatment 
must  be  fixation  in  the  horizontal  position,  for  in  this  position  the 
strain  of  use  and  the  pressure  of  superincumbent  weight  can  be 
removed  completely. 


THE  CONVEX  STRETCHER  FRAME  63 

Horizontal  Fixation. — Apparatus  for  this  treatment  must  be 
quite  independent  of  the  bed  on  which  it  may  be  placed,  and  of 
such  apphances  several  forms  are  in  use. 

The  reclinationgypsbettes  of  Lorenz^  is  simply  a  posterior  case 
of  plaster  of  Paris  enclosing  the  head  and  body. 

The  Phelps  bed  is  somewhat  similar.  A  thin  board  is  cut  in 
the  outline  of  the  child's  body  and  extended  legs.  It  is  padded 
with  wadding  and  covered  with  cotton  cloth;  the  patient  is  then 
placed  upon  it,  and  plaster  bandages  are  applied  to  enclose  the 
body  and  the  legs.  The  front  is  then  cut  away,  so  that  the  patient 
may  be  removed  from  the  bed  for  an  occasional  bath  and  change 
of  clothing.^ 

The  wire  cuirasse  has  been  popularized  by  Sayre;^  it  is  some- 
what more  €umbersome  and  expensive  than  the  last  appliance 
for  which  it  served  as  a  model. 


Fig.  29. — Bradford's  bed  frame.     (Bradford  and  Lovett.) 

The  most  effective  and  convenient  form  of  this  type  of  simple 
horizontal  support  is  the  Bradford  frame.  This  is  a  rectangular 
frame  of  gas-pipe  a  few  inches  longer  and  slightly  wider  than  the 
patient's  body.  Over  the  frame  covers  of  strong  canvas  are  drawn 
tightly  by  means  of  corset  lacings  or  straps  on  its  under  surface, 
leaving  an  interval  beneath  the  buttocks  for  the  use  of  the  bed- 
pan (Fig.  29). 

THE  CONVEX  STRETCHER  FRAME. 

The  stretcher  frame^  is  a  modification  of  that  of  Bradford  designed 
to  assure  correction  of  deformity  in  some  degree  with  more  direct 
support  and  less  interference  with  the  clothing.  It  is  made  of 
ordinary  galvanized  gas-pipe  or  steel  tubing  of  a  smaller  diameter. 
It  should  be  about  four  inches  longer  than  the  child  and  about  four- 
fifths  as  wide,  the  lateral  bars  corresponding  to  the  articulating 
surfaces  of  the  four  extremities  with  the  trunk.     The  ordinary 

1  Hoffa:  Lehrbucb  der  Orthop.  Chir.,  3d  ed.,  p.  324. 

2^"he  Phelps  Plaster-of-Paris  Bed:  Tr.  Am.  Orthop.  Assn.,  1891,  iv,  83. 

2'Iledard:  La  gouttiere  de  Bonnet,  Chir.  Orthop.,  p.  243. 

4  Whitman:  Tr.  Am.  Orthop.  Assn.,  1901. 


64 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


dimensions  are  seven  and  one-half  by  thirty-eight  inches,  or  the 
width  to  length  about  as  one  to  five. 

At  first  thought  it  would  seem  that  the  side  bars  might  cause 
uncomfortable  pressure  on  the  overhanging  shoulders,  but  as  the 
arms  are  set  upon  the  middle  of  the  lateral  aspect  of  the  trunk 
and  thus  on  a  considerably  higher  plane  than  the  dorsum,  there 
is  but  bare  contact  when  the  cover  is  fairly  rigid.  Before  applying 
the  cover  one  may  with  advantage  wind  bandages  tightly  about 
the  frame  at  the  point  which  is  to  support  the  trunk  in  order  to  make 


Fig.  30. — The  modified  frame  with  tlie  bandage. 

the  support  as  unyielding  as  possible  (Fig.  30).  The  cover  should 
be  of  strong  canvas  suitably  protected  in  the  centre  by  rubber 
cloth.  This  is  applied  and  is  drawn  tight  by  means  of  corset  lacings 
and  straps.  Upon  this  two  thick  pads  of  felt  are  sewed;  these 
should  be  about  seven  inches  in  length  and  about  an  inch  in  thick- 
ness, placed  on  either  side  of  the  spinous  processes  at  the  seat  of  the 
disease,  thus,  protecting  them  from  pressure,  fixing  the  part  more 
firmly,  and  increasing  the  leverage  of  the  apparatus.  The  child, 
wearing  only  an  undershirt,  stockings,  and  diaper,  is  placed  upon 


Fig.  31. — The  stretcher  frame,  showing  the  canvas  cover  and  apron. 


the  frame  and  is  fixed  there  usually  by  a  front  piece  or  apron  similar 
to  that  used  with  the  spinal  brace.  As  soon  as  the  patient  has 
become  accustomed  to  the  restraint  one  begins  to  overextend  the 
spine  by  bending  the  bars  from  time  to  time  with  the  aim,  as  has 
been  stated,  of  actually  separating  the  diseased  vertebral  bodies 
and  obliterating  all  the  physiological  curves  of  the  spine,  so  that  the 
body  shall  be  finally  bent  backward  to  form  the  segment  of  a  circle. 
The  greatest  convexity  is  at  the  seat  of  the  disease,  and  as  the  head 
and  lower  extremities  are  on  a  much  lower  level,  an  element  of 


THE  CONVEX  STRETCHER   FRAME 


65 


gravity  traction  is  present  in  some  instances,  while  the  support  of 
the  spine,  as  a  whole,  is  much  more  comprehensive  than  when  the 
body  lies  upon  a  plane  surface  (Fig.  32).  The  gradual  overexten- 
sion of  the  spine  by  bending  the  frame  in  this  manner  is  so  definite 
and  simple  that  it  may  be  easily  carried  out  by  the  physician,  and 
it  may  be  exaggerated  slightly,  to  compensate  for  the  sagging  of 


Fig.  32.- 


-The  frame  bent  to  assure  overextension  of  the  spine.     The  rapid  recession 
of  deformity  in  this  case  is  shown  by  the  tracings,  Fig.  28. 


the  cover.  Thus,  it  is  far  more  efi'ective  than  any  form  of  padding 
placed  on  a  flat  surface,  or  other  form  of  support  with  which  I  am 
familiar.  Upon  this  frame  the  child  lies  constantly,  its  clothing 
being  made  sufficiently  large  to  include  the  apparatus,  thus  assuring 
additional  fixation.  Once  a  day  or  less  often,  the  child  is  removed 
from  the  frame  and  is  carefully  turned,  face  downward,  upon  a  large 
pillow;  the  back  is  then  inspected,  bathed  with  alcohol  and  pow- 
dered, and  the  apparatus  is  then  reapplied.  It  is,  of  course,  desir- 
able to  have  two  equipped  frames,  but  this  is  by  no  means  essential. 


Fig.  33. — The  modified  stretcher  frame  showing  overextension  of  the  spine,  with 
traction  for  the  head  and  limbs  as  applied  for  Pott's  paraplegia,  caused  by  disease 
in  the  upper  dorsal  region.     (See  Fig.  56.) 

The  efi^ect  of  the  continued  fixation  upon  the  back  is  not  merely 
to  change  the  contour  of  the  spine,  but  of  the  entire  trunk  as  well; 
to  flatten  and  broaden  the  thorax.  This  increase  of  the  lateral  at 
the  expense  of  the  anteroposterior  diameter  is  quite  the  reverse 
of  the  natural  tendency  of  the  deformity,  and  it  is  therefore  a 
favorable   rather   than   an   unfavorable   effect   of  the   treatment. 


66  TUBERCULOUS  DISEASE  OF   THE  SPINE 

The  same  tendency  in  the  lower  region  may  be  cheeked  by  the  use 
of  a  flannel  binder,  such  as  is  ordinarily  worn  by  infants. 

The  method  of  attaching  the  patient  to  the  frame  varies  some- 
what according  to  the  situation  and  character  of  the  disease.  In 
ordinary  cases,  as  has  been  stated,  a  canvas  apron,  similar  to  that 
used  with  the  back  brace  (Fig.  63),  is  applied,  and  is  buckled  to 
the  sides  of  the  frame.  If  advisable  the  shoulders  may  be  held 
down  by  bands  crossing  the  chest  or  by  axillary  straps  connected 
by  a  chest  band.  If  still  more  effective  fixation  is  desired,  as  in 
disease  of  the  upper  dorsal  region,  the  anterior  shoulder  brace, 


Fig.  34. — A  perfect  cure  obtained  by  the  stretcher  treatment.     The  situation  of  the 
disease  is  shown  in  the  .r-ray  picture,  Fig.  35. 

as  used  with  the  back  brace  (Fig.  65),  may  be  attached  to  the 
axillary  straps.  In  disease  of  the  upper  and  middle  regions  of  the 
spine  restraint  of  the  legs  is  not  necessary,  but  in  lumbar  disease 
a  broad  swathe  should  be  passed  across  the  thighs,  and  if  psoas 
spasm  is  present  traction  may  be  employed. 

If  the  disease  is  of  the  upper  region  and  if  the  patient's  head 
is  of  the  long  type,  it  is  advisable  to  make  a  right  angular  doA\-n- 
w^ard  bend  of  the  side  bars  so  that  the  occiput  being  on  a  lower 
level  the  proper  pressure  at  the  seat  of  disease  may  be  assured. 

In  disease  of  the  upper  region  of  the  spine  traction  is  desir- 


THE  CONVEX  STRETCHER  FRAME 


67 


able  to  aid  in  the  reduction  of  deformity  and  to  prevent  the  patient 
from   raising  the  head.     This  traction  is  usually  applied  by  means 


Fig.  35. — An  x-ray  picture  of  the  case  (Fig.  34)  before  treatment.  The  situation 
of  the  disease  at  the  junction  of  the  first  and  second  lumbar  vertebrae  is  indicated  by 
the  lateral  deviation,  and  by  the  approximation  of  the  dotted  lines  1  and  2  as  com- 
pared to  the  others. 


68  TUBERCULOUS  DISEASE  OF   THE  SPINE 

of  the  halter  as  used  with  the  jury-mast.  The  straps  are  attached 
to  a  crossbar  at  the  upper  extremity  of  the  frame,  and  traction  may 
be  made  by  simply  tightening  them ;  or  if  the  upper  part  of  the  frame 
is  somewhat  elevated,  the  weight  of  the  patient's  body  makes  the 
proper  counter-traction.  This  position  has  the  advantage,  also, 
of  allowing  the  patient  a  better  opportunity  to  see  what  is  going 
on  about  him  (Fig.  33). 

In  disease  of  the  cervical  region  traction  is  usually  of  service 
and  restraint  of  the  head  is  always  indicated  in  addition,  when 
the  occipto-axoid  region  is  involved,  either  by  sand-bags  on  either 
side,  or,  preferably,  by  some  form  of  metal  brace. 


Fig.  .36. — The  baby  carriage  as  used  in  hospital  practice  for  patients  on  the  stretcher 

frame. 

Direct  fixation  of  the  spine  may  be  desirable  in  cases  of  more 
acute  disease.  This  may  be  attained  by  the  use  of  a  light  back 
brace,  or  a  plaster  jacket,  in  connection  with  the  frame.  Such 
support  should  not  be  applied,  however,  until  the  recession  of 
deformity,  which  is  to  be  expected  under  treatment  by  the  hori- 
zontal fixation  and  overextension,  has  been  obtained   (Fig.  28). 

As  this  frame  is  simply  a  horizontal  brace  the  child  may  spend 
as  much  time  in  the  open  air  as  would  be  practicable  were  any 
other  appliance  used. 

I  have  never  seen  other  than  favorable  results  from  this  method 
of  treatment.  Pain  and  discomfort  are,  as  a  rule,  relieved  almost 
immediately,  and  there  is  a  corresponding  improvement  in  the 
general  condition  of  the  patient.  ^leanwhile  the  growth  of  the 
trunk,  which  is  so  often  checked  by  the  disease  and  by  the  de- 
formity, appears  to  progress  normally,  so  that  the  apparatus  may 


THE  CONVEX  STRETCHER  FRAME 


G9 


be  actually  outgrown  before  the  termination  of  this  part  of  the  treat- 
ment. Horizontal  fixation  is,  of  course,  a  treatment  not  complete 
in  itself,  since  it  must  be  supplemented  by  the  usual  supports  when 


Fig.  37. — Pott's  disease  of  the  middle  dorsal  region,  a  type  of  disease  in  which  hori- 
zontal fixation  is  always  indicated.    H.  S.,  aged  fourteen  months. 


Fig.  38. 


-H.  S.,  after  fixation  for  fourteen  months  on  the  stretcher  frame,  shows  the 
recession  of  deformity.     Compare  with  Fig.  37. 


70  TUBERCULOUS  DISEASE  OF   THE  SPINE 

the  erect  attitude  is  again  assumed.  Its  duration  varies  from  six 
to  eighteen  months.  The  indications  for  its  discontiimance  are  the 
correction  of  deformity,  the  apparent  quiescence  or  cure  of  the  local 
disease  as  indicated  by  the  physical  signs,  and  by  the  behavior  of 
the  patient,  who,  as  repair  advances,  becomes  restless  when  re- 
moved from  the  frame,  evidently  desiring  to  sit  and  to  stand. 

It  is  well  to  apply  the  ambulatory  support  some  time  before 
the  patient  is  released  from  the  frame,  permitting  little  by  little 
the  changes  in  attitude  and  habits.  If  the  plaster  jacket  is  to 
be  used  it  may  be  applied  during  longitudinal  suspension  or  other- 
wise, after  which  the  child  is  immediately  replaced  upon  the  frame, 
where  the  plaster  is  allowed  to  harden;  thus  it  holds  the  spine  in 
an  attitude  to  which  it  has  become  accustomed  (Fig.  56). 

Ambulatory  Supports. — The  two  t^'pes  of  ambulatory  supports 
are  the  plaster  jacket  and  the  steel  brace.  The  first  of  these  has 
the  great  advantage  in  that  the  services  of  a  skilled  mechanic  are 
not  essential  and  in  that  the  patient  is  more  under  the  control  of 
the  physician  than  when  removable  apparatus  is  used. 

The  Plaster  Jacket. — It  was  claimed  at  one  time  that  a  plaster 
jacket  applied  while  the  body  was  partially  suspended  would 
actually  relieve  the  weakened  area  of  superincumbent  weight  by 
holding  the  diseased  surfaces  apart.  This  is  not  the  fact.  The 
jacket  supports  the  spine  by  holding  it  in  the  erect  or  extended 
position  and  thus  transferring  the  weight  in  part  from  the  dis- 
eased vertebral  bodies  to  the  lateral  and  posterior  portion  of  the 
column. 

Its  efficiency  depends  upon  the  accuracy  of  its  adjustment  to 
the  contour  of  the  trunk,  and  upon  the  leverage  that  it  exerts 
above  and  below  the  weakened  part.  It  should  be  applied  while 
the  body  is  held  in  the  best  possible  position;  its  inner  surface 
should  be  smooth,  and  the  bony  prominences  that  are  exposed  to 
friction  and  pressure  should  be  protected. 

A  seamless  shirt  fitting  the  body  closely  and  long  enough  to 
reach  to  the  knees  should  be  worn.  These  are  made  in  several  sizes 
and  are  sold  by  the  yard  at  a  low  price.  A  band  of  linen,  China  silk 
or  other  material,  about  three  inches  in  width  and  three  feet  in 
length,  should  be  placed  beneath  the  shirt  on  the  front  and  back. 
These  bands,  or,  as  Lorenz  calls  them,  "scratchers,"  are  for  the 
purpose  of  keeping  the  skin  clean.  The  patient  is  then  placed  upon 
a  stool,  and  the  halter  of  the  suspension  apparatus  is  carefully 
adjusted;  the  arms  are  extended  over  the  head  and  the  hands 
clasp  the  straps  or  rings;  thus,  the  chest  is  expanded  to  its  full 
limit.  Sufficient  tension  is  made  upon  the  rope  to  partially  sus- 
pend the  body  and  to  draw  the  spine  into  the  best  possible  atti- 
tude; in  most  instances  the  heels  should  be  slightly  lifted  from  the 
stool. 

Dr.  Sayre,  to  whom  we  are  indebted  for  the  exposition  of  this 


THE  PLASTER  JACKET  71 

valuable  means  of  treatment,  insisted  that  the  sensations  of  the 
patient  should  be  the  guide  and  that  traction  should  be  made 
only  to  the  point  of  comfort.  This  is  a  valuable  indication  in 
the  treatment  of  the  adult,  but  it  is  not  often  of  service  in  child- 
hood. 


Fig.  40. — The  plaster  jacket  support- 
FiG.  39. — The  plaster  jacket,  illustrat-         ing  the  abdomen.      The  cleansing  ban- 
ing  the  arrangement  of  the  shirt.  dages   are   not  shown. 

Before  applying  the  plaster  bandages  pieces  of  piano  felting  or 
similar  material  of  sufficient  thickness  are  placed  about  the  anterior 
pelvic  spines,  over  the  upper  part  of  the  sternum,  and  a  thin  strip 
is  sometimes  used  to  cover  the  spinous  processes.  Finally,  long 
pads  of  saddler's  felt,  or  of  other  material  of  sufficient  thickness, 


72  TUBERCULOUS  DISEASE  OF   THE  SPIXE 

are  applied  on  either  side  of  the  prominent  spinous  processes  to 
protect  them  from  friction  and  to  provide  greater  pressure  and 
fixation  at  the  seat  of  disease.  In  the  treatment  of  adolescent 
or  adult  females  the  breasts  should  be  covered  with  a  layer  of  cotton, 
which  may  be  removed  later,  if  necessary,  to  prevent  pressure. 
The  "dinner  pad"  is  now  not  often  used,  except  in  the  treatment 
of  adults  and  in  certain  cases  in  which  the  abdomen  is  retracted. 
In  childhood  the  abdomen  is  usually  prominent,  and  extra  space  is 
not  usually  required.  Occasionally,  however,  one  is  told  that  the 
patient  complains  of  discomfort  after  meals,  evidently  due  to  con- 
striction, and  in  such  cases  proper  allowance  must  be  made.  The 
pad,  which  is  supposed  to  represent  the  space  necessary  after  a  full 
meal,  is  made  by  folding  a  small  towel  into  the  shape  of  a  sandwich; 
this  is  attached  to  a  bandage  and  is  placed  beneath  the  shirt  just 
below  the  ensiform  cartilage;  when  the  jacket  is  completed  it  may 
be  drawn  out  by  means  of  the  hanging  bandage,  leaving  the  addi- 
tional space  for  emergencies. 

The  materials  for  the  jacket  should  be  of  the  best.  Fresh  dental 
plaster  should  be  rubbed  by  hand  into  strips  of  crinoline,  free  from 
glue.  The  bandages  should  be  from  three  to  five  inches  in  width 
and  six  yards  in  length,  from  three  to  six  being  required  for  a 
jacket,  according  to  the  size  of  the  child.  They  should  be  placed 
on  end,  in  a  pail  of  warm  water,  one  at  a  time  as  they  are  used.  Xo 
salt  or  alum  should  be  used  to  hasten  the  setting  of  the  plaster; 
in  fact,  if  such  aid  is  necessary  it  is  unfit  for  use.  When  the  bubbles 
have  ceased  to  rise  the  bandage  is  squeezed  gently  until  no  water 
drips  from  it,  and  the  loose  threads  are  removed  from  the  ends. 

One  person  should  sit  behind  the  patient  and  one  in  front,  while 
the  third  may  hold  the  rope  and  check  the  swaying  of  the  body. 
The  one  who  sits  behind  the  patient  may  clasp  the  child's  legs 
between  his  knees  and  thus  assure  better  fixation  of  the  pelvis. 
The  pads  are  held  in  position  until  they  are  fixed  by  the  plaster 
bandages,  which  should  be  applied  with  a  slight  and  even  ten- 
sion. 

As  a  rule  the  jacket  should  be  of  uniform  thickness  through- 
out. This  thickness  need  not  exceed  one-eighth  to  one-fourth  of 
an  inch,  and  it  may  even  be  lighter  in  certain  cases.  It  is  well 
to  begin  by  figure-of-eight  turns  about  the  waist  and  pelvis  with 
sufficient  tension  to  bring  into  relief  the  pelvic  crests,  since  the 
pelvis  is  the  base  of  support;  and,  as  the  most  important  point 
for  counter-pressure  is  the  upper  part  of  the  chest,  the  appliance 
should  be  made  especially  strong  and  resistant  at  this  point. 

During  the  application  of  the  jacket  it  should  be  rubbed  con- 
stantly in  order  that  the  difterent  layers  of  bandage  may  adhere 
to  one  another,  and  that  it  may  fit  the  projections  of  the  pelvis 
and  body  closely.  ^Meanwhile  the  attitude  of  the  patient  should 
be  carefully  watched,  in  order  to  prevent  lateral  inclination  of 


THE   PLASTER  JACKET 


the  body.  It  is  often  possible  while  the  patient  is  suspended  to 
correct  the  deformity  still  further  by  backward  traction  on  the 
shoulders  and  forward  pressure  on  the  trunk  while  the  jacket 
is  hardening. 

When  the  jacket  is  nearly  firm  it  should  be  trimmed.  In 
many  instances  this  may  be  done  while  the  patient  is  in  the 
swing,  but  if  he  is  fatigued  he  may  be  placed  in  the  recumbent 
posture. 

As  a  rule  the  front  of  the  jacket  should  reach  from  the  upper 
margin  of  the  sternum  to  the  pubes;  behind,  from  about  the 
midline  of  the  scapula?  to  the  gluteal  fold;  laterally,  it  should  be 
cut  away  sufficiently  to 
prevent  chafing  of  the 
arms ;  and  on  either  side  of 
the  pubes  an  oval  section 
is  cut  out,  to  allow  for  the 
flexion  of  the  thighs  in  the 
sitting  posture.  Particular 
attention  is  called  to  the 
importance  of  making  the 
jacket  as  long  as  possible, 
so  that  the  abdomen  may 
be  contained  within  it  in- 
stead of  being  forced  out 
beneath  its  lower  border 
(Fig.  40).  After  the  ap- 
plication of  the  jacket  the 
patient  should  remain  in 
the  recumbent  posture  for 
at  least  half  an  hour  or 
longer,  as  it  does  not  be- 
come absolutely  firm  for 
several  hours.  The  shirt 
is  then  drawn  up  over  the 
jacket  and  is  sewed  to  the 
neck  portion;  this  adds 
much     to     neatness     and 

cleanliness.  The  shirt  must  be  drawn  tightly  about  the  neck,  in 
order  to  guard  the  body  from  the  crumbs  or  other  objects  that  may 
fall  beneath  the  jacket,  and  in  many  instances  a  special  protector 
in  the  form  of  a  wide  collar  bib  may  be  used  with  advantage. 

The  upper  and  lower  ends  of  the  cleansing  bandages  are  joined 
to  one  another  with  tape,  and  with  them  the  skin  is  carefully  rubbed 
twice  daily.     When  soiled  they  may  be  replaced. 

It  may  be  mentioned  in  this  connection  that  even  the  slightest 
excoriation  or  irritation  of  the  skin  beneath  the  jacket  can  be 
detected  by  the  peculiar  odor.     Of  this  parents  should  be  informed, 


Fig.  41. — The  jury-mast  and  the  anterior 
support. 


74 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


so  that  it  may  be  cut  down  and  the  source  of  the  irritation  removed 
at  once.     With  ordinary  care  "sores,"  the  bugbear  of  the  plaster 


Fig.  42. — The  jurj--mast. 

jacket,  may  be  avoided  or  so  quickly  detected  that  they  are  of  little 
consequence.     From  the  mechanical  stand-point  the  plaster  support 

is  most  satisfactory  in  the  treatment 
j^mm  HI^^^^^MI      ^^  disease  of  the  dorsolumbar  region, 

^K^  •    ^p55^    ^^^^^^H      ^^^  efficiency  lessening  with  the  dis- 
^^    ^.^irm     '  tance  from  this  central  point. 

If  the  disease  is  above  the  tenth 
dorsal  vertebra  it  is  well  to  carry 
the  plaster  bandages  about  the  neck 
and  in  front  of  the  shoulders  as  in 
the  Calot  jacket  or  direct  backward 
traction  on  the  shoulders  may  be 
made  by  means  of  the  anterior 
shoulder  brace  described  in  con- 
nection with  the  spinal  brace  (Fig. 
41) ;  this  may  be  attached  to  buckles 
incorporated  in  the  plaster  or  by 
tapes  crossed  behind  the  shoulders. 
Traction  applied  in  this  manner  is 
an  additional  fixation  for  the  spine 
and  assures  better  expansion  of  the 
chest.  In  default  of  this  appliance 
the  shoulders  may  be  included  in  the 
plaster  support. 

In  many  instances  a  head  support 
is  required,  and  it  is,  of  course,  al- 
ways indicated    in   disease  of   the 
upper  dorsal  and  cervical  regions. 
^.       ,o     T11    ^    .•      c    i-        c     For  this  purpose  the  head  mav  be 

iiG.    43. — Illustrating  fixation   of      .  -^      -f        , 

head  in  the  overextended  attitude.      mcluded  m  the  plaster  support  Or  a 


THE   PLASTER- JACKET 


75 


jury-mast  or  a  posterior  splint  may  be  employed.  The  jury-mast 
should  be  of  tempered  steel,  strong  enough  to  hold  its  shape 
under  the  tension  of  the  halter  (Fig.  42).  Its  base  should  be 
incorporated  firmly  in  the  jacket  below  the  seat  of  the  disease; 
it  should  be  long  enough  to  reach  well  above  the  head,  and  the 
crossbar  should  be  placed  directly  over  the  ears  (Fig.  46) . 

The  halter  should  be  applied  with  as  much  tension  as  can  be 
borne  comfortably  by  the  patient,  so  that  the  weight  of  the  head 

may  be  at  least  partly  sup- 
ported. The  straps  should*  be 
adjusted  to  tilt  the  chin  slightly 
upward,  the  aim  being  to  draw 


Fig.  44. — A  fixation  support  for  the 
head.  This  may  be  used  with  the  brace 
or  with  the  jacket. 


Fig.  45. — Front  view  of  the  same  patient. 


the  head  backward  and  thus  to  extend  the  spine.  In  disease  of  the 
cervical  region  the  crossbar  should  be  fixed  to  check  lateral  motion 
of  the  head,  but  this  is  unnecessary  when  it  is  at  a  lower  level. 

If  fixation  of  the  head  is  desired,  or  if  the  jury-mast  is  ineffective, 
an  appliance  similar  to  that  shown  in  Fig.  44  may  be  used.  This 
consists  of  two  light  steel  bars,  incorporated  like  the  jury-mast  in 
the  jacket,  and  adjusted  to  the  neck  and  back  of  the  head.  Their 
upper  extremities  are  joined  by  a  band  of  light  steel  of  U-shape, 
long  enough  to  reach  from  ear  to   ear,   the  circumference  being 


76  TUBERCULOUS  DISEASE  OF   THE  SPINE 

completed  by  a  band  of  tape  across  the  forehead.  In  certain 
instances  additional  straps  may  be  placed  beneath  the  chin  and 
the  occiput,  as  in  Figs,  44  and  45.  In  this  connection  it  may  be 
stated  that  the  support  provided  by  the  jury-mast  is  only  effective 
when  it  is  carefully  adjusted  and  constantly  watched.  In  most 
instances,  therefore,  a  rigid  apparatus,  though  less  comfortable,  is 
to  be  preferred. 

If  the  jacket  is  carefully  fitted  to  the  pelvis  it  may  be  a  fairly 
efficient  support  even  if  the  disease  is  in  the  lower  lumbar  region. 
If,  however,  the  symptoms  are  acute  with  accompanying  spasm 
of  the  flexors  of  the  thigh  it  should  be  extended  to  one  or  both 
knees  as  a  single  or  double  spica  according  to  the  indications. 


Fig.  46. — The  jacket  and  jury-naast  applied.    The  same  patient  is  shown  in  Fig.  33. 

The  Calot  Jacket. — Calot  was  at  one  time  an  advocate  of  the 
immediate  correction  of  the  deformity  of  Pott's  disease,  a  treat- 
ment described  in  previous  editions  of  this  book.  Although  the 
method  is  no  longer  used,  it  served  a  purpose  in  calling  atten- 
tion to  the  importance  of  more  eft'ective  preventive  treatment, 
and  it  has  further  been  demonstrated  that  the  deformity  may  be 
corrected  to  the  same  degree,  as  far  as  the  final  result  is  concerned, 
by  milder  methods.     One  of  these  is  the  convex  stretcher  frame 


THE  CALOT  JACKET 


77 


in  recumbency,  and  another  is  the  Calot  jacket  in  ambulatory 
treatment. 

The  essentials  of  the  Calot  support  are  fixation  of  the  neck 
and  shoulders  as  well  as  of  the  pelvis,  and  direct  pressure  over 
the  kyphosis,  the  front  of  the  jacket  having  been  cut  away  so 
that  the  trunk  may  be  forced  forward,  thus  straightening  the 
spine  as  a  whole,  and  in  some  degree  the  local  deformity. 


Fig.  47. — The  Calot  jacket,  show- 
ing the  application  to  the  neck  and 
shoulders. 


Fig.  48. 


-The   Calot  jacket,  showing  the 
pad  and  hooks. 


In  applying  the  support  the  patient  is  partly  suspended  in 
the  ordinary  manner.  If  the  head  is  to  be  included  a  special 
sling  must  be  used.  This  may  be  improvised  from  bandage  ma- 
terial, but  preferably  it  is  made  of  canvas.  It  should  be  about 
five  or  six  feet  in  length  and  two  and  a  half  inches  in  width,  the 
ends  are  sewed  together,  making  when  it  is  passed  over  the  cross- 
bar, two  loops,  of  which  one  is  placed  about  the  chin  and  the  other 


78  TUBERCULOUS  DISEASE  OF   THE  SPINE 

beneath  the  occiput.  These  are  attached  to  one  another  by  safety 
pins  above  the  ears.  To  the  posterior  loop  a  similar  band  about 
three  and  a  half  feet  in  length  is  sewed.  This  when  carried  behind 
the  occiput  and  attached  to  the  crossbar  holds  the  head  firmly 
in  the  desired  position  if  it  is  to  be  included  in  the  support.  A 
close-fitting  shirt  with  a  high  neck  and  sleeves  is  worn.  The  pro- 
tecting pads  are  then  applied  in  the  usual  manner  and  a  band  of 
felt  is  placed  about  the  neck.     In  addition  the  front  of  the  thorax 


Fig.  49. — The  Calot  jacket,  showing  the  thick  block  of  wood  used  for  pressure  over 
the  felt  pads.  For  this  detail  in  the  pressure  appliance  I  am  indebted  to  Dr.  G.  E. 
Bennett. 

is  covered  with  a  layer  of  cotton  batting  about  one  inch  in  thick- 
ness. The  arms  are  supported  at  a  right  angle  to  the  trunk  and  the 
jacket  is  constructed,  if  the  disease  is  of  the  lower  dorsal  region,  to 
include  the  neck  and  shoulders.  As  a  part  is  to  be  cut  away  it  must 
be  made  much  thicker  than  the  ordinary  jacket,  especially  over 
the  shoulders,  on  the  lateral  borders  of  the  chest  and  about  the 
deformity.  Calot  constructs  the  jacket  with  layers  of  crinoline 
previously  cut  in  patterns,  which  are  then  saturated  with  liquid 


THE  CALOT  JACKET 


79 


plaster  mixture,  but  those  accustomed  to  the  roller  bandages  will 
prefer  them,  strengthening  the  jacket  by  reverses  in  the  usual 
manner. 

When  the  jacket  is  sufficiently  firm  the  patient  is  placed  upon 
the  back  and  a  small  triangular  opening  is  cut  over  the  chest  through 
which  the  thoracic  pad  is  removed,  so  that  respiration  may  not  be 
constrained.  The  following  day,  or  when  the  jacket  is  thoroughly 
dry,  the  front  is  cut  away  as  illustrated  in  the  pictures.     Another 


Fig.  50. — The  Calot  jacket,  showing  the  head  support  and  hooks. 

opening  is  made  in  the  back  to  thoroughly  expose  the  area  of  the 
disease.  A^aseline  is  then  applied  to  the  skin  and  pads  of  cotton 
one  after  the  other  are  forced  into  the  opening  to  the  point  of  tolera- 
tion, with  the  aim  of  pressing  the  trunk  forward  and  flattening  the 
projection.  These  pads  are  held  in  place  by  turns  of  plaster 
bandage  or  by  adhesive  plaster.  The  procedure  is  repeated  at 
intervals  of  several  weeks,  the  pressure  if  possible  being  increased. 
A  more  accurate  adjustment  of  the  corrective  force  and  one 


80  TUBERCULOUS  DISEASE  OF   THE  SPINE 

that  permits  inspection  of  the  spine  and  thus  lessens  the  danger 
of  pressure  sores  is  as  follows:  The  pads  are  made  of  thick  felt 
arranged  to  press  on  either  side  of  the  spinous  processes.  Over 
them  is  placed  a  thick  piece  of  wood  of  the  exact  size  of  the  open- 
ing. Pressure  is  made  by  two  firm  bands  of  tape  buckled  to  metal 
hooks  fixed  to  the  lateral  margins  of  the  jacket. 

If  the  disease  is  of  the  upper  third  of  the  spine  the  bead  should 
be  supported.  The  sling  is  adjusted  to  hold  the  head  in  a  position 
of  slight  extension.  The  shirting  is  drawn  over  the  head,  an 
opening  having  been  cut  for  the  face.  The  neck,  chin  and  occiput 
are  protected  with  felt  or  cotton  and  the  plaster  is  applied  about 
the  head;  the  sling  is  then  removed  and  the  support  cut  to  the 
shape  shown  in  the  illustration  (Fig.  50) .  The  shirting  is  afterward 
sewed  in  the  usual  manner. 

The  Calot  jacket  is  difficult  to  adjust,  but  it  is  far  more  effective 
than  any  other  form  of  ambulatory  support. 

The  Application  of  the  Jacket  in  the  Recumbent  Posture. — The 
jacket  may  be  applied,  while  the  patient  lies  extended  in  the  prone 
posture,  by  the  hammock  method  suggested  by  Davy,  of  London. 

A  long  narrow  strip  of  cotton  cloth  is  passed  under  the  shirt 
and  is  drawn  tight  enough,  by  means  of  a  pulley  or  by  manual 
traction,  to  support  the  trunk  in  the  proper  attitude,  preferably, 
of  course,  in  overextension.  An  opening  is  cut  for  the  face,  and 
if  advisable,  traction  may  be  made  on  the  arms  and  legs  of  the 
patient.  The  bandages  are  then  applied  in  the  ordinary  manner, 
after  which  the  cloth  may  be  cut  short  at  one  end  and  removed. 

This  method  is  of  service  in  the  treatment  of  weak  or  par- 
alyzed patients,  but  the  adjustment  is  somewhat  less  satisfactory 
than  by  the  ordinary  method  in  that  the  fixation  of  the  thorax 
is  less  accurate.  The  jacket  may  be  applied  in  the  supine  posture 
by  means  of  the  Goldthwait  apparatus.  This  may  be  employed 
also  in  the  routine  application  of  the  plaster  jacket. 

It  consists  essentially  of  a  support  (Fig.  51)  carrying  on  its 
upper  extremities  two  thin  strips  of  perforated  metal.  To  these 
strips  felt  is  attached,  forming  pads  similar  to  those  used  on  the 
back  brace.  The  patient  is  then  placed  with  his  back  resting  on 
the  pads  at  the  seat  of  the  disease.  The  buttocks  and  the  head 
are  allowed  to  sink  downward  to  the  point  of  toleration;  thus  an 
extending  force  is  exerted  on  the  spine.  The  plaster  bandages 
are  then  applied  in  the  usual  manner  about  the  body  on  either 
side  of  the  support.  When  it  is  completed  the  patient  is  lifted 
from  the  support,  the  pads  being  included,  of  course,  in  the  jacket. 
An  opening  remains  at  this  point  that  may  be  closed  by  an 
additional  bandage. 

Other  supports  of  a  similar  nature  are  in  use,  but  as  they  do  not 
differ  from  it  in  principle  a  detailed  description  is  unnecessary 
(Figs.  52  and  53). 


THE  PLASTER  JACKET 


81 


Fig.  51. — The||]application  of  the  jacket  in  the  recumbent  posture  by  means  of  the 
Goldthwait  appliance;  A,  the  support,  similar  to  that  upon  which  the  patient  is 
lying;  B,  two  thin  bands  of  steel,  similar  to  those  used  in  the  Taylor  brace. 


Fig.  52. — -R.  Tunstall  Taylor's  apparatus  for  the  application  of  the  plaster  jacket 
in  the  recumbent  posture,  consisting  of  an  adjustable  back  support  and  pelvic  rest, 
connected  by  a  sliding  bar.      (See  Fig.  53.) 


Fig.  53. — The  Taylor  appliance  in  use,  showing  the  hyperextension  of  the  spine. 
The  plaster  jacket  having  been  applied,  the  back  rest  is  removed  by  pressing  the 
bandages  from  side  to  side  or  by  enlarging  the  opening.     If  desirable,  the  defect  is 
then  concealed  by  a  turn  of  plaster  bandage. 
6 


82 


TUBERCULOUS  DISEASE  OF   THE  SPIXE 


If  the  deforirjity  is  of  recent  origin  it  may  be  actually  cor- 
rected by  the  leverage  exerted,  but  in  many  instances  the  hyper- 
extension  takes  place  in  the  unaffected  parts  of  the  spine^  par- 


FiG.  54. — Goldthwait's  portable  frame  for  applj-ing  the  plaster  jacket. 

ticularly  in  the  lumbar  region.  Thus  the  correction  is  apparent 
rather  than  actual.  In  order  to  prevent  this  and  to  exert  more 
effective  leverage  on  the  deformity  Goldthwait  uses  the  appara- 
tus illustrated  in  Fig.  54. 


^^^^^d 


Fig.  .55. — The  plaster  jacket  applied  in  supine  postirre  by  means  of  the  Metzger- 

Goldthwait  apparatus. 

The  patient  lies  on  two  maheable  steel  bars  fitted  to  the  lum- 
bar region  reaching  only  to  the  apex  of  the  deformity.  The  plaster 
bandages  forming  the  lower  part  of  the  jacket  having  been  apphed, 
the  upper  portion  of  the  trunk  is  allowed  to  sink  downward  to  the 


THE  PLASTER  JACKET  83 

point  of  toleration  and  the  jacket  is  then  completed.  The  steel 
bars  which  have  prevented  the  upward  arching  of  the  lumbar 
region  of  the  spine  are  then  withdrawn.  The  Metzger  apparatus, 
of  which  that  last  described  is  an  adaptation,  which  permits  longi- 
tudinal traction  as  well  as  direct  leverage  is  shown  in  Fig.  55. 

The  Application  of  the  Jacket  to  Patients  Who  have  been  Treated 
on  the  Stretcher  Frame. — A  satisfactory  method  of  applying  a 
plaster  jacket  to  young  subjects,  when  the  deformity  has  been 
corrected  in  whole  or  in  part  by  recumbency  on  the  frame  in  the 
overextended  position,  is  the  following:  The  patient  is  suspended 
face  downward  in  the  horizontal  position  by  two  assistants,  one 
holding  the  arms  and  the  other  the  thighs;  thus,  a  certain  amount 
of  traction  is  exerted,  while  the  weight  of  the  body  tends  to  over- 
extend  the  spine. 

In  this  attitude  a  jacket  is  quickly  applied,  and  the  child  is 
at  once  replaced  upon  the  frame,  which  has  been  protected  by  a 
rubber  sheet  (Fig.  56).     The  plaster  jacket,  during  the  harden- 


FiG.  56. — The  stretcher  frame  on  which  the  patient  is  replaced  while  the  jacket  is 

hardening. 

ing  process,  must  conform  to  the  habitual  posture  of  recumbency. 
The  pressure  pads  of  the  frame  indent  the  bandage  on  either  side 
of  the  spinous  processes  (Fig.  57)  and  thus  afford  better  support 
and  fixation.  This  is  a  very  satisfactory  method  of  applying 
the  jacket  in  this  class  of  cases  because  it  is  not  necessary  to  retain 
the  child  in  an  uncomfortable  position  while  the  support  is  harden- 
ing, and  because  accuracy  of  adjustment  in  the  best  possible  atti- 
tude is  assured. 

For  the  routine  application  of  the  plaster  jacket  vertical  sus- 
pension is  to  be  preferred,  because  in  this  more  natural  attitude 
the  support  may  be  more  accurately  and  comfortably  adjusted. 
The  hammock  method  and  that  just  described  are  of  particular 
service  in  the  treatment  of  young  subjects.  The  supine  posture 
may  be  selected  with  advantage  when  the  spine  is  sufficiently 
flexible  at  the  seat  of  disease  to  permit  a  certain  degree  of  cor- 
rection or  if  the  patient  is  weak  or  timid  or  paralyzed. 

As  a  rule  a  jacket  may  be  worn  for  two  months,  although  not 


84 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


infrequently  it  may  remain  for  six  months,  or  even  longer,  and 
yet  be  fairly  efficient.  Usually  one  jacket  is  removed  and 
another  applied  on  the  same  day,  but  if  the  skin  is  at  all  sensitive 
it  is  well,  after  the  washing  and  powdering,  to  reapply,  the  old 
jacket,  closmg  it  with  adhesive  plaster,  and  allow  an  interval  of  a 
few  days  before  applying  the  permanent  one. 


Fig.  57. 


-Jacket  applied  by  the  stretcher  method,  showing  the  depressions  on  either 
side  caused  by  the  frame  pads. 


The  Plaster  Corset. — In  the  stage  of  recovery  the  jacket  may  be 
replaced  by  a  corset.  A  jacket,  made  and  trimmed  as  already 
described,  is  cut  down  the  centre  and  removed  from  the  body. 
It  is  carefully  readjusted  to  its  former  shape,  bandaged  with  the 
cut  sm-faces  in  close  apposition,  and  is  thoroughly  dried  or  baked. 

All  wrinkles  are  then  cut  away  from  the  inner  surface,  and 
extra  padding  is  applied  if  necessary;  the  shirt  is  drawn  tightly 
about  the  borders  of  the  jacket  and  strips  of  leather  provided 
with  hooks  are  sewed  in  front  so  that  it  may  be  laced  like  an 
ordinary  corset.  It  may  be  removed  from  time  to  time  to  allow 
for  bathing,  but  it  should  always  be  removed  and  reapplied  while 
the  patient  is  suspended  or  in  the  recumbent  position. 

The  corset  is  sometimes  used  in  place  of  the  jacket  during  the 
active  stage  of  the  disease,  but  it  is  less  effective,  since  the  repeated 
stretching  during  removal  and  reapplication  weakens  the  appliance 


THE  BACK  BRACE 


85 


and  impairs  the  accuracy  of  adjustment.  In  addition,  one  of  the 
strongest  arguments  in  favor  of  the  use  of  plaster  of  Paris,  that 
treatment  is  under  control  of  the  surgeon,  is  nullified. 

Corsets  of  other  Material  than  Plaster  of  Paris. — Corsets  of  wood, 
leather,  paper,  poroplastic  felt,  celluloid  or  aluminium  are  some- 
times used.  These  are  constructed  on  a  plaster  cast  of  the  body, 
an  accurately  fitting  jacket  being  used  as  a  mold. 

Such  corsets  have  certain  advan- 
^^|(fnTir  tages  of  durability  and  elegance, 

but  none  of  them  has  the  accuracy 
of  fit  of  the  plaster-of -Paris  corset, 
■which  is  molded  directly  on  the 
body.  Corsets  of  this  class  are 
usually  somewhat  expensive,  and 
on  that  account  are  often  worn 
after  they  are  outgrown  or  when 
they  no  longer  fit  the  patient. 
Their  use  is  practically  limited  to 
the  stage  of  recovery  or  for  other 
affections  than  Pott's  disease. 


Fig.  58. — The  Taylor  back  brace. 
(H.  L.  Taylor.) 


Fig.  59. — The  Taylor  chest-piece.  Two 
triangular  pads  of  hard  rubber  connected 
by  a  bar. 


The  Back  Brace. — ^The  spinal  brace,  or  spinal  assistant,  as  the 
original  appliance  of  Dr.  C.  F.  Taylor  was  called,  consists  essenti- 
ally of  two  steel  bars  that  are  applied  on  either  side  of  the  spinous 
processes  from  the  top  to  the  bottom  of  the  spine.  At  the  seat 
of  the  disease  pads  are  placed  to  provide  for  greater  pressure  and 
fixation,  and  to  form  a  fulcrum  over  which  the  spine  may  be  straight- 
ened or  held  erect,  when  the  two  extremities  of  the  brace  are  firmly 
attached  to  the  pelvis  and  to  the  shoulders.  The  attachment  at 
the  lower  end  is  made  by  means  of  a  pelvic  band  of  sheet  steel 
(gauge  18)  from  one  and  a  half  to  two  inches  in  width,  long  enough 


86 


TUBERCULOUS  DISEASE  OF   THE  SPIXE 


to  reach  from  one  iliac  spine  to  the  other;  it  is  placed  as  low  as  pos- 
sible on  the  pelvis;  in  other  words,  just  above  the  upper  extremities 
of-  the  trochanters.  To  this  the  uprights  are  firmly  attached  at  an 
interval  of  from  one  and  a  quarter  to  one  and  three-quarter  inches 
from  one  another,  so  that  the  spinous  processes  may  pass  between 
them,  while  pressure  is  made  on  the  lateral  masses  of  the  vertebrae. 
The  uprights  are  made  of  varying  strength,  according  to  the  age  of 
the  patient,  usually  about  one-half  an  inch  in  width  (of  gauge  8 
to  12)  and  of  such  quality  of  steel  that,  although  unyielding  to  the 
strain  of  use,  it  may  be  readily  bent  by  wrenches,  and  thus  accurately 


Fig.  60. — Backward  traction  on  the  shoul- 
der fixes  the  upper  dorsal  region. 


Fig.  61. — The     anterior    shoulder 
brace  and  its  attachment. 


adjusted  to  the  back.  The  uprights  reach  to  the  root  of  the  neck, 
or  to  about  the  level  of  the  second  dorsal  vertebrte;  from  tliis  pomt 
two  short  arms  of  metal  project  forward  and  outward  on  either  side 
of  the  neck,  reaching  to  about  the  middle  of  the  clavicles.  To  these 
padded  shoulder  straps  are  attached  which  pass  through  the  axillae 
to  a  crossbar  on  the  back  brace;  thus  downward  pressure  on  the 
shoulders  is  avoided  and  increased  leverage  is  assured  (Fig  62) . 

Opposite  the  area  of  disease  two  strips  of  thin  steel  about  tliree 
inches  in  length  are  fixed;  these  are  slightly  wider  than  the  up- 
rights and  are  perforated  for  the  attaclmient  of  the  pressure  pads, 
which  mav  be  made  of  la  vers  of  canton  flannel  or  felt,  or  unvielding 


THE  BACK  BRACE  §7 

material,  such  as  leather  or  hard  rubber,  may  be  used  instead. 
The  pads  should  project  from  a  quarter-  to  a  half-inch  in  front  of 
the  uprights  in  order  that  firm  and  constant  pressure,  to  the  degree 
that  the  skin  will  tolerate,  may  be  made  at  the  seat  of  disease 
(Fig.  58).      _ 

In  measuring  for  this  braCe  the  patient  is  placed  in  the  prone 
posture  and  a  tracing  of  the  outline  of  the  back  is  made  by  means 
of  the  lead  tape.     This  outline  may  be  cut  in  cardboard  and  fitted 


Fig.  62. — The  Taylor  brace  and  head  support  applied  for  disease  of  the  upper  dorsal 

region. 


to  the  back;  in  fact,  if  the  mechanic  is  unfamiliar  with  the  work, 
each  part  of  the  brace,  uprights,  pelvic  band,  etc.,  may  be  cut  in 
cardboard  and  attached  to  one  another  to  serve  as  a  model.  Be- 
fore the  brace  is  finished  it  should  be  applied  to  the  back  and  should 
be  adjusted  carefully  by  means  of  wrenches.  The  pelvic  band  and 
the  parts  that  come  into  direct  contact  with  the  skin  are  usually 
covered  with  leather,  or,  in  the  treatment  of  young  children,  with 
rubber  plaster  and  canton  flannel  to  prevent  rusting. 

If  the  brace  is  applied  before  the  stage  of  deformity  it  should 


88 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


follow  the  exact  shape  of  the  spine,  but  if  deformity  is  present, 
particularly  in  disease  of  the  thoracic  region,  it  should  be  made 
somewhat  straighter,  in  order  to  permit  a  gradual  correction  of 
the  compensatory  lordosis  in  the  lumbar  region,  and  for  increased 
leverage  above  the  deformity.  As  has  been  stated,  a  certain  degree 
of  recession  of  deformitv  can  be  obtained  bv  rest  in  the  horizontal 


WmM 

^K^I^k^^Sa^^H 

^^^^^fcy.  ^Slfj^^^B 

V   i    /fl| 

'^  v"^^B 

I                  yP^-     ^1 

■: -....aiii-^         •  Ate^i.  ^^^Ml 

Fig.  63. — The  Taylor  brace  and  head 
support  appUed  to  the  patient  shown  in 
Fig.  69. 


Fig.   64. — The  Taylor  brace  with  jurj'- 
mast. 


position,  and  if  practicable  this  improved  contour  should  be  attained 
before  the  brace  is  applied.  The  apparatus  is  held  in  place  by  an 
"apron"  (Fig.  63),  which  covers  the  chest  and  abdomen,  to  which 
straps  are  attached,  Ordinarily  this  is  made  of  strong  linen  or 
cotton  cloth,  but  a  canvas  front  shaped  accurately  to  the  body 
and    strengthened    with    whalebone   is    a   more   comfortable   and 


THE  BACK  BRACE 


89 


efficient  support.  In  applying  the  brace  the  pelvic  band  is  first 
attached  to  the  apron,  then  the  straps  in  order,  from  below  upward, 
and,  finally,  the  shoulder  straps.  Each  strap  is  tightened  until 
the  brace  is  firmly  fixed  in  proper  position.  If  the  a  brace  is  properly 
applied  and  properly  fitted  it  holds  its  place  by  friction,  but  when 
the  disease  of  the  lower  lumbar  region,  or  if  the  brace  has  a  tend- 
ency to  upward  displacement  perineal  straps  should  be  used  to 
hold  the  pelvic  band  firmly  in  its  place  (Fig.  58).     At  first  the 


Fig.  65.- 


-The  Taylor  back  brace  and  head  support  combined  with  the  Whitman 
anterior  support. 


brace  is  removed  once  a  day  in  order  to  wash  and  powder  the  back, 
the  same  care  being  observed  in  moving  the  child  as  in  the  treat- 
ment by  the  frame;  but  after  the  skin  has  become  accustomed  to 
the  pressure  the  brace  should  be  removed  only  at  infrequent  inter- 
vals, and,  thus,  if  desirable,  only  under  the  supervision  of  the 
surgeon. 

This  description  indicates  the  essential  qualities  of  the   back 
brace.     It  has  been  modified  in  various  ways;  for  example,  Dr. 


90 


TUBERCULOUS  DISEASE  OP  THE  SPINE 


Taylor  eventually  discarded  the  straight  pelvic  band  in  favor  of 
one  of  a  U-shape  (Fig.  58).  This  makes  the  brace  somewhat 
lighter  and  relieves  the  sacrum  from  pressure,  but  it  does  not  add 
to  its  effectiveness.  The.  efficiency  may  be  increased,  however, 
by  modifying  the  upper  attachment,  as  is  illustrated  in  Fig.  59,  in 
which  two  triangular  pads  of  hard  rubber  connected  by  a  metal  bar 
are  employed. 

This  is  an  improvement  on  the  simple  shoulder  straps  of  the 
original  brace,  but  it  does  not  provide  the  quality  of  support  and 
fixation  thatiis  desirable  when  the  disease  is  of  the  upper  or  middle 
segment  of  the  thoracic  region.    In  such  cases  the  upper  part  of  the 


Fig.   66. — The  anterior  shoulder  brace. 


Fig.  67. — The  scapular  pads. 


chest  is  flattened,  the  inclination  of  the  ribs  is  increased,  and  the 
shoulders  droop  forward,  carrying  with  them  the  scapulae.  Thus 
the  weight  and  the  strain  of  the  motion  and  use  of  the  arms  tend 
to  increase  the  deformity. 

In  health  direct  forward  or  reaching  movements  of  the  arms 
are  always  accompanied  by  an  increase  in  the  posterior  curva- 
ture of  the  dorsal  spine.  On  the  other  hand,  if  the  shoulders  are 
drawn  backward  and  held  in  this  attitude,  the  curvature  of  the  spine 
is  lessened  and  the  chest  is  elevated  and  expanded  (Fig.  60). 

In  the  treatment  of  disease  of  the  upper  dorsal  region  it  should 
be  the  aim,  in  the  application  of  a  brace,  to  follow  this  indication 
and  to  apply  pressure  directly  upon  the  extremities  of  the  shoulders 


THE  BACK  BRACE 


91 


to  assure  the  greatest  possible  fixation  of  the  spine  and  to  restrain 
the  movements  of  the  arms  that  tend  to  increase  the  deformity. 

The  diagrams  illustrated  in  Fig.  61  show  how  such  support  may 
be  applied.  Two  saucer-shaped  plates  of  hard  rubber  or  padded 
metal  (Fig.  65)  cover  the  heads  of  the  humeri  *and  are  joined  by  a 
rigid  bar  of  steel,  which  passes  across  but  does  not  touch  the  chest. 
On  the  back  brace  are  placed  two  triangular  pads  of  similar  con- 
struction, which  cover  and  press  upon  the  scapulae.  These  pads 
are,  however,  not  essential 
and  are  often  omitted.  The 
back  brace  is  applied,  the 
shoulders  are  then  drawn 
backward  and  the  shoulder- 
cups  are  firmly  attached  by 
straps  to  the  neck  bars  of 
the  brace    above,   and   by 


■ 

\^l 

^^^V    1              1^ 

^^1 

p.^-^;€: 

■ 

It  "'  '^ 

i^^^l 

^^^^m  K 

^^^1 

^^^Vv 

^^^1 

V^l 

g| 

Fig.  68. — The  loop  head  support. 


Fig.  69. — Disease  of  the  middle  cervical 
region,  showing  the  deformity  and  attitude. 
This  patient  had  been  paralyzed  for  one  year 
before  treatment  was  begun.     (See  Fig.  63.) 


axillary  bands  below  in  the  usual  manner.  By  this  means  the 
thorax  is  elevated  and  the  spine  is  more  effectively  fixed,  while 
direct  movement  of  the  arms  forward  is  made  impossible.  It 
would  seem  that  such  restraint  would  be  irksome  to  the  patient, 
but  in  an  extended  use  of  the  apparatus  this  has  never  caused 
complaint.  In  many  instances,  even  when  the  disease  is  as  low 
as  the  tenth  dorsal  vertebra,  it  may  be  used  with  advantage,  but 
it  is  especially  indicated  when  the  disease  is  in  the  neighborhood 


92  TUBERCULOUS  DISEASE  OF   THE  SPINE 

of  the  seventh  dorsal  vertebra.  In  connection  with  the  shoulder 
brace  it  is  usually  advisable  to  apply  a  support  beneath  the  chin 
to  prevent  the  forward  inclination  of  the  neck  and  to  tilt  the  head 
somewhat  backward.  A  very  simple  and  inoffensive  support,  of 
this  character  is  a  loop  of  steel  surrounding  the  neck  and  attached 
by  screws  to  a  back  bar  on  the  brace  (Fig.  68) .  If  a  more  efficient 
brace  is  required,  as  when  the  disease  is  of  the  upper  dorsal  or  cer- 
vical regions,  the  Taylor  head  support  should  be  used.  This  is 
an  oval  ring  of  steel  which  may  be  clasped  about  the  neck  by  means 
of  a  lateral  hinge.  On  the  front  a  cup  of  hard  rubber  supports  the 
chin  and  behind  the  ring  fits  upon  an  upright  pivot  that  may  be 
raised  or  lowered  upon  a  crossbar  on  the  upper  part  of  the  brace; 
free  lateral  motion  is  allowed,  or  it  may  be  checked  by  means  of 
a  screw  (Fig.  62). 

If  absolute  fixation  of  the  head  is  indicated,  as  in  disease  at 
or  near  the  occipito-axoid  region,  two  steel  uprights  may  be  attached 
to  the  back  of  the  ring;  these  are  bent  to  fit  the  posterior  and  lateral 
aspect  of  the  head  closely,  and  a  band  of  webbing  is  passed  from 
one  upright  to  the  other  and  about  the  forehead. 

In  applying  the  support  the  chin  should  always  be  tilted  slightly 
upward  in  order  to  throw  the  weight  of  the  head  backward  (Fig. 
63).  The  adjustment  of  the  head  support  is  made  easier  if  the 
pivot  is  attached  to  the  upright  by  means  of  a  ball-and-socket  joint 
(Shaffer — Fig.  62)  that  may  be  regulated  by  a  screw  and  key;  this 
arrangement  is  of  service  when  the  head  is  distorted,  but  it  is  by 
no  means  necessary. 

When  the  Taylor  head  support  or  similar  appliance  is  used  the 
greater  part  of  the  pressure  is  sustained  by  the  chin,  which  may, 
after  a  time,  undergo  an  unsightly  recession.  It  may  be  of  adyan- 
tage,  therefore,  in  such  cases,  and  particularly  when  restraint 
of  the  motion  of  the  neck  is  desirable,  to  transfer  this  pressure  to 
the  forehead  and  occiput  by  extending  the  back  bars  upward  over 
the  back  of  the  head  (Fig.  43). 

A  jury-mast  may  be  used  to  support  the  head  also,  its  adjust- 
ment as  described  in  connection  with  the  plaster  jacket  (Fig.  64). 

Comparison  of  the  Two  Forms  of  Ambulatory  Support. — The  most 
severe  criticisms  of  the  jacket  have  been  made,  by  those  unfamiliar 
with  its  use,  on  theoretical  grounds  rather  than  from  actual  observa- 
tion. While  it  is  apparent  that  there  are  certain  objections  to  the 
support,  yet  experience  has  shown  that  when  it  is  applied  in  a 
proper  manner  under  proper  conditions  it  is  a  thoroughly  reliable, 
efficient,  and  often  indispensable  means  of  treatment.  Indeed,  it 
may  be  stated  that  by  means  of  the  various  forms  of  support  that 
may  be  constructed  of  plaster  of  Paris  it  is  possible  to  treat  suc- 
cessfully nearly  every  case  of  Pott's  disease  without  the  aid  of  the 
professional  brace-maker. 

It  is  evident  that  under  certain  conditions  a  fixed  support  must  be 


THE   THOMAS  COLLAR 


93 


inferior  to  the  adjustable  brace,  in  early  childhood  for  example,  when 
the  pelvis  is  undeveloped.  Again,  when  the  disease  is  low  down,  at 
or  near  the  lumbosacral  junction,  the  lower  border  of  the  jacket  does 
not  hold  the  pelvis  with  sufficient  security  to  provide  the  proper 
support.  In  the  upper  dorsal  region  the  attachments  for  accurate 
fixation  may  be  adjusted  more  readily  to  the  brace,  and  in  disease 
of  the  cervical  region  the  metallic  head  support  is  to  be  preferred 
to  the  halter  of  the  jury-mast,  for  the  reason  that  it  cannot  be 
removed  by  the  patient.  The  traction  of  the  jury-mast  is  very 
effective  when  properly  used,  and  particularly  so  when  painful 
distortion  of  the  neck  is  present,  but  the  tension  on  the  strap  is 
rarely  constant,  and  thus  it  loses  in  efficiency.  A  rigid  support  is, 
of  course,  preferable  in  the  disease  of  the  atlo-axoid  region.  The 
Calot  support,  though  cumbersome  and  somewhat  difficult  of  ad- 
justment, is  perhaps  the  most  efficient  means  of  treatment  of  disease 
of  the  upper  region  of  the  spine.  It  is,  of  course,  least  satisfactory 
during  the  warm  months. 

The  jacket  is  most  serviceable  in  the  region  from  the  tenth 
dorsal  to  the  second  lumbar  vertebra.  It  is  not  only  effective, 
but  it  is  often  a  more  comfortable  support 
than  the  spinal  brace.  It  is  more  satisfac- 
tory when  lateral  deviation  of  the  spine  is 
present,  and  from  the  clinical  stand-point  it 
is  often  more  efficacious  in  relieving  pain  in 
this  region  when  the  disease  is  at  all  acute. 
One  may  conclude,  then,  that  each  form  of 
support  may  be  used  according  to  the  indi- 
cations. The  absolute  control  of  the  treat- 
ment, assured  by  the  use  of  the  plaster 
jacket,  will  often  overbalance  the  claims  of 
the  brace. 

Other  Forms  of  Support. — In  certain  cases 
of  disease  of  the  lower  lumbar  region  it  may 
be  advisible  to  restrain  the  movements  of 
the  thighs,  although  ordinarily,  when  this 
is  necessary,  ambulation  should  be  dis- 
continued. Such  restraint  may  be  at- 
tained by  making  the  back  bars  of  the 
brace  stronger  and  extending  them  down  the  thighs  to  the  knees 
like  a  double  Thomas  hip  brace. 

If  the  jacket  is  used  it  may  be  extended  to  a  single  or  double 
spica  for  the  same  purpose  as  has  been  mentioned.  Such  appli- 
ances are  useful  when  psoas  spasm  and  "cramp"  are  trouble- 
some symptoms. 

In  disease  of  the  cervical  region  a  certain  amount  of  support 
and  fixation  may  be  obtained  by  collars  of  poroplastic  felt,  plaster 
of  Paris,  or  other  material.     The  Thomas  collar  (Figs.  71  and  72) 


Fig.  70.— a  light  sup- 
port of  steel  and  cellu- 
loid for  disease  of  the 
cervical  region.    (Baeyer.) 


94 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


is  the  best  of  this  type  of  support,  but  none  of  them  is  thoroughly 
efficient  unless  used  with  a  brace  to  control  the  larger  movements 


Fig.  71.- 


-The  Thomas  collar  of  leather  stuffed  with  cotton.     (Ridlon  and  Jones.) 


Fig  72  —The  Thomas  collar  for  permanent  use.  A  piece  of  thm  sheet  metal  is 
cut  wide  enough  to  reach  from  the  sternum  to  the  chin,  and  from  the  back  of  the 
neck  to  the  base  of  the  occiput.  The  edges  are  turned  out  and  the  whole  properly 
covered  with  felt  and  fitted.     (Ridlon  and  Jones.) 


Fig. 


73. — The  Thomas  collar  applied. 
(Ridlon  and_ Jones.) 


Fig.  74. — The  knight  brace  with 
the  back  bars  prolonged  to  support 
the  head. 


SPECIAL  INDICATIONS  95 

of  the  spine.  They  are  useful  in  emergencies,  but  they  are  not 
often  required  when  proper  braces  can  be  obtained. 

In  the  final  stage  of  treatment  the  Knight  brace,  a  light  steel 
frame  with  corset  front,  may  be  used  (Fig.  74)  or  a  long  corset 
similar  to  that  ordinarily  worn  by  women,  but  strengthened  by 
the  insertion  of  light  steel  bars,  may  be  sufficient. 

Many  other  forms  of  apparatus  of  greater  or  less  merit  might 
be  described,  but  space  has  permitted  only  a  detailed  account  of 
three  forms  representing  the  essential  principles  involved  in  the 
treatment  of  Pott's  disease. 

The  Principles  of  Treatment  in  Their  Practical  Application. — The 
effect  of  treatment  must  be  estimated  not  simply  by  its  relief 
of  the  symptoms  of  the  disease,  since  deformity  may  increase  in 
spite  of  the  apparent  well-being  of  the  patient,  but  it  must  be 
selected  and  continued  or  changed  with  the  aim  of  combating 
ultimate  deformity,  and  on  this  standard  success  or  failure  must 
be  determined. 

Indications  for  Treatment  by  Recumbency. — As  has  been  stated 
already,  the  most  important  influence  toward  deformity  is  the 
force  of  gravity;  therefore  horizontal  fixation  in  overextension 
is  the  most  efficient  means  of  preventing  deformity,  and  of  assuring 
the  rest  that  favors  repair. 

It  is  indicated  as  the  routine  treatment  in  infancy  and  in  early 
childhood  up  to  the  age  of  four  years  at  least. 

In  many  instances  absolute  recumbency  may  not  be  required, 
but  the  period  of  activity  must  be  carefully  regulated,  and  must 
be  discontinued  when  there  is  evidence  of  discomfort  or  weak- 
ness or  pain.  If  the  period  of  activity  must  be  short,  it  should 
be  passed  in  the  open  air.  The  passive  attitude  of  sitting,  although 
less  strain  is  thrown  upon  the  spine  than  during  activity,  may  be 
even  worse  for  the  patient;  thus  the  reclining  or  semireclining 
posture  should  be  assumed  as  a  rule,  when  the  child  is  in  the  house, 
at  least  during  the  active  stage  of  the  disease.  Even  if  the  spine 
appears  to  be  perfectly  supported,  the  time  spent  in  bed  should  be 
long,  and  a  period  of  rest  in  the  middle  of  the  day  should 
be  enforced. 

The  arguments  in  favor  of  horizontal  fixation  in  early  child- 
hood do  not  apply  to  disease  in  the  adult.  At  this  age  the  struc- 
ture of  the  spine  is  resistant,  and  deformity  is  little  to  be  feared, 
while  such  confinement  would  be  irksome  and  impracticable; 
thus  local  support,  supervision,  and,  if  possible,  a  change  of  cli- 
mate must  be  the  treatment  of  selection  for  the  adolescent  or  adult. 

In  the  middle  period  of  childhood,  from  the  fifth  to  the  tenth 
year,  horizontal  fixation  is  the  treatment  for  emergencies;  for 
paralysis,  for  abscess,  for  dangerous  disease  of  the  atlo-axoid 
region,  for  progressive  deformity,  and  for  pain  that  cannot  be 
relieved  by  the  ordinary  means. 


96 


TUBERCULOUS  DISEASE  OF   THE  SPINE 


Special  Indications  for  Treatment  of  Diseases  of  the  Differ- 
ent Regions  of  the  Spine. — In  the  selection  of  treatment  and 
in  the  general  management  of  Pott's  disease  each  region  of  the 
spine  must  be  judged  by  itself,  since  in  each  there  are  special 
difficulties  to  be  met,  and  complications  to  be  feared  that  may 
influence  the  prognosis  and  lead  to  modifications  of  the  routine 
of  treatment. 


Fig.  75. — The  final  result  of  extreme 
bilateral  psoas  contraction.  The  direct 
bone  deformity  being  comparatively 
slight. 


Fig.  76. — Final  resxilt  of  lumbar 
disease;  spontaneous  absorption  of 
abscess,  and  but  slight  deformity. 
(See  Fig.  13.) 


The  Lower  Region. — The  prognosis  is  good  in  disease  of  the 
lower  region,  and  one  may,  as  a  rule,  predict  recovery  without 
noticeable  deformity;  at  most  but  a  slight  shortening  and  broaden- 
ing of  the  trunk  and  a  peculiar  erectness  of  attitude. 

The  brace  is  the  better  support  when  the  disease  is  near  the 
sacrum,  while  the  jacket   is   often  more  comfortable  and  more 


COMPLICATIONS  OF  POTT'S  DISEASE  97 

•  effective  than  the  brace  when  the  middle  or  upper  himbar  region 
is  diseased,  particularly  when  lateral  deviation  of  the  spine  is 
present. 

The  most  troublesome  complications  of  this  region  are  psoas 
contraction  and  the  abscess  with  which  it  is  often  com- 
bined. 

As  has  been  stated,  psoas  contraction  changes  the  attitude 
of  overerectness,  favorable  to  repair,  to  a  forward  stoop  that 
increases  the  pressure  and  friction  at  the  seat  of  disease.  If  this 
attitude  persists  and  if  it  becomes  fixed  by  permanent  changes, 
such  as  are  likely  to  follow  the  burrowing  of  a  pelvic  abscess,  most 
disastrous  deformity  may  result;  the  body  and  the  thighs  are 
approximated  and  the  erect  attitude  is  made  impossible.  In 
neglected  c*ases  of  this  character,  division  of  the  contracted  tissues 
and  forcible  correction  or  even  subtrochanteric  osteotomy  may  be 
necessary  to  overcome  the  secondary  deformity.  In  ordinary  cases 
of  psoas  contraction,  and  when  one  limb  only  is  flexed,  the  patient 
may  be  allowed  to  go  about  with  crutches,  using  a  high  shoe  on  the 
unaffected  side,  so  that  the  flexed  limb  n,eed  not  affect  the  attitude. 
If,  however,  the  contraction  persists,  it, is  well  to  place  the  patient 
on  a  frame,  and  to  reduce  the  flexion  by  traction  in  the  line  of 
deformity,  or  it  m,ay  be,  directly  reduced  under  anesthesia,  fixation 
in  the  extended  position  being  assured  by  a  spica  jacket,  as  will  be 
described  in  the  treatment  of  disease,  of  the  hip-joint.  Persistant 
psoas  contraction  is  almost  always  a  symptom  of  abscess  about  the 
origin  or  in  the  substance  of  the  muscle,  and  when  it  is  accompanied 
by  pain  it  is  always  an  evidence  of  progressive  disease. 

Abscess  may  be  expected  as  a  complication  in  at  least  50  per 
cent,  of  the  cases  of  disease  of  this  region,  but  it  is  by  no  means 
always  accompanied  by  psoas  contraction,  nor  is  psoas  contraction 
always  symptomatic  of  abscess.  Abscess  unaccompanied  by  con- 
traction usually  has  its  origin  above  the  lumbar  region,  and  does 
not  involve,  therefore,  the  substance  of  the  psoas  muscle.  The 
treatment  of  abscess  is  considered  elsewhere. 

Disease  of  the  Middle  and  Upper  Dorsal  Region. — This  is,  from 
the  stand-point  of  prevention  of  deformity,  the  most  difficult 
region  of  the  spine  to  treat,  although  the  symptoms  of  the^disease 
may  be  easily  relieved. 

Deformity  is  present  in  nearly  all  cases  when  treatment  is 
sought,  and  it  is  difficult  to  check  its  progress  for  the  reasons 
that  have  been  stated  already. 

The  final  result  in  the  majority  of  cases  is  what  appears  to  be 
exaggerated  round  shoulders;  the  neck  is  shortened  and  projects 
forward,  the  chest  is  flat,  and  the  shoulders  are  high. 

In  all  cases  of  disease  above  the  ninth  vertebra,  the  shoulders 
should  be  restrained  to  secure  greater  fixation  of  the  spine;  and 
in  all  cases  above  the  seventh  or  eighth  vertebra  a  head  or  chin 


98  TUBERCULOUS  DISEASE  OF   THE  SPINE 

support  is  indicated  in  addition.     It  is  in  the  treatment  of  disease 
of  this  region  that  the  Calot  jacket  is  particularly  indicated. 

Paralysis  is  a  frequent  complication  of  disease  in  this  region. 
When  it  appears  after  treatment  is  begun,  it  usually  indicates  in- 
efficient fixation  of  the  spine  or  want  of  caution  in  regulating  the 
strain  to  which  the  diseased  part  is  subjected.  Its  symptoms  and 
its  treatment  will  be  considered  later. 

Disease  of  the  Upper  Dorsal  and  Middle  Cervical  Region. — This 
is  the  most  favorable  region  of  the  spine  for  treatm^ent.  The 
disease  is  usually  not  extensive  because  of  the  small  size  and  com- 
pact structure  of  the  vertebrae,  and  the  mobility  of  the  cervical 
region  is  so  great  that  it  readily  compensates  for  the  local  rigidity. 
Under  efficient  treatment  one  may  predict  recovery  without  notice- 
able deformity,  and  in  the  less  successful  cases  it  is  not,  as  a  rule, 
offensive.  The  shoulders  appear  high,  the  neck  is  short,  the  head 
inclines  forward,  while  the  back  is  abnormally  flat  in  compensation 
for  the  change  in  contour  of  the  part  above. 

When  the  case  of  cervical  disease  is  first  brought  for  treat- 
ment a  wry-neck  deformity,  often  made  more  persistent  by  the 
infiltration  of  an  abscess  or  by  enlarged  cervical  glands,  is  almost 
always  present.  As  a  means  of  correcting  this  distortion,  the  jury- 
mast  and  traction  halter  is  a  very  efficient  and  comfortable  sup- 
port. Under  its  constant  tension  the  deformity  may  be  corrected 
with  ease,  but  as  a  permanent  treatment  more  exact  fixation  by 
means  of  the  metallic  support  or  the  Calot  jacket  is  preferable. 

Disease  of  the  Occipito-axoid  Region. — Under  efficient  treatment 
the  prognosis  is  good,  and  recovery  without  deformity  should  be 
the  rule.  The  course  of  the  disease,  although  it  is  often  accom- 
panied by  acute  symptoms,  is  usually  short,  as  compared  with  that 
of  other  regions  of  the  spine.  It  may  be  assumed  that,  in  many, 
cases,  it  is  primary  arthritis,  or,  at  least,  that  the  primary  focus 
in  the  atlas  or  axis  is  very  small  The  disease  at  this  point  is, 
however,  in  close  proximity  to  the  vital  centres,  and  sudden  death 
from  displacement  and  pressure  on  the  cord  is  not  uncommon. 
Abscess  is  frequent,  and  it  is  often  a  troublesome  and  dangerous 
complication. 

If  wry-neck  deformity  is  present  it  should  be  reduced  by  trac- 
tion either  in  bed  or  by  means  of  the  jury-mast.  The  head  should 
then  be  fixed  in  an  attitude  of  slight  extension  by  an  efficient  head 
brace  or  by  the  Calot  or  similar  support.  Recumbency  is  indi- 
cated during  acute  phases  of  the  disease. 

Abscess  Complicating  Pott's  Disease. — A  limited  collection  of 
tuberculous  fluid  is  present  at  some  time  during  the  course  of  Pott's 
disease  in  the  great  majority  of  cases,  an  assumption  usually  con- 
firmed by  .T-ray  examination,  but  unless  it  appears  as  a  palpable 
tumor  above  or  below  the  thorax  or  upon  the  surface  of  the  body 
its  presence  is  not  often  detected. 


ABSCESS  IN  POTT'S  DISEASE  99 

Townsend/  in  380  cases  of  Pott's  disease  examined  with  refer- 
ence to  the  occurrence  of  abscess  as  a  compHcation,  found  that  it 
was  present  or  had  been  detected  in  75  (19.7  per  cent.) ;  in  8  per 
cent,  of  the  cases  of  cervical  disease;  in  20  per  cent,  of  the  dorsal, 
and  in  72  per  cent,  of  those  in  which  the  lumbar  region  was  involved. 

Dollinger,^  in  700  cases  under  treatment  from  1883  to  1895, 
found  abscess  in  154  (22  per  cent.);  in  13  of  63  cases  in  the  cer- 
vical region  (22.6  per  cent.);  in  47  of  403  cases  in  the  thoracic 
region  (11.6  per  cent.);  and  in  94  of  234  cases  of  lumbar  disease 
(40.17  per  cent.). 

Ketch,^  in  75  cured  cases  of  Pott's  disease  treated  at  the  New 
York  Orthopedic  Dispensary,  selected  for  the  purpose  of  con- 
trasting the^  behavior  of  the  disease  in  the  different  regions  of 
the  spine,  found  that  abscess  had  appeared  in  19  (25.3  per  cent.). 
In  the  upper  region  abscess  was  detected  in  but  1  of  the  25  cases 
(4  per  cent.);  in  the  middle  region  in  8  of  the  25  cases  (32  per 
cent.),  and  in  the  lower  in  10  (40  per  cent.). 

In  354  autopsies  by  Mohr,  Nebel,  Bouvier,  and  Lannelongue 
abscess  was  found  in  281,  or  nearly  80  per  cent. 

Although  cases  of  Pott's  disease  that  come  to  autopsy  may  be 
supposed  to  represent  a  severe  type  of  disease,  yet  it  is  evident, 
by  contrasting  the  statistics,  that  a  large  proportion  of  the  ab- 
scesses escape  detection  in  the  living.  One  may  conclude,  then, 
that  abscess  may  be  expected  as  a  more  or  less  serious  complica- 
tion in  25  per  cent,  of  all  cases  of  Pott's  disease,  and  in  at  least 
half  of  those  in  which  the  lower  region  of  the  spine  is  affected. 
The  greater  frequency  here  is  explained  by  the  large  size  and 
less  resistant  structure  of  the  vertebral  bodies  as  compared  with 
those  of  the  upper  regions. 

The  tuberculous  abscess  is  separated  from  the  neighboring 
parts  by  a  limiting  wall  varying  in  thickness  according  to  its 
age,  the  outer  layers  of  which  are  of  fibrous  and  cellullar  tissue, 
the  inner  of  granulation  tissue  covered  with  yellowish-gray  or 
pinkish-gray  necrotic  membrane,  which  is  easily  separated  from 
the  underlying  parts.  The  fluid  of  the  abscess  is  usually  of  a 
whitish  or  whey-like  color,  composed  of  serum,  leukocytes,  and 
emulsified  caseous  material  and  fibrin.  Floating  in  it  are  masses 
of  cheesy  necrotic  tissue  and  sometimes  minute  fragments  of  bone, 
which  settle  to  the  bottom  of  the  glass.  Certain  of  the  smaller 
quiescent  abscesses  contain  only  this  whitish  semisolid  material. 
The  fluid  of  abscesses  in  process  of  resolution  is  often  clear,  like 
serum ;  but  if  secondary  infection  has  taken  place  the  pus  is  of  a 
greenish-yellow  color,  and  is  of  uniform  consistency.  At  any 
stage  of  its  progress  the  abscess  may  become  stationary  and  its 

1  Tr.  Am.  Orthop.  Assn.,  iv,  166. 

2  Loc.  cit. 

3  Tr.  Am.  Orthop.  Assn.,  iv,  200. 


100  TUBERCULOUS  DISEASE  OF   THE  SPIXE 

contents  may  be  absorbed;  in  fact,  such  an  outcome  is  not  unusual. 
The  fluid  of  the  abscess  is  usually  sterile,  and  secondary  infection, 
before  a  communication  with  the  exterior  of  the  body  is  established, 
is  uncommon. 

Abscess  is  a  symptom  of  disease,  and  it  is  in  some  degree  an 
evidence  of  its  character.  If  it  appears  early  and  increases  in 
size  rapidly  it  usually  indicates  a  destructive  and  rapidly  ad- 
vancing process.  On  the  other  hand,  the  slowly  enlarging  or 
quiescent  abscess  has  but  little  significance.  The  abscess  may 
cause  no  sATnptoms  whatever,  or  it  may  be  a  source  of  incon- 
venience simply  because  of  its  size  or  situation.  In  many  in- 
stances, however,  a  period  of  malaise  or  discomfort  or  pain  is 
followed  and  explained  by  the  appearance  of  an  abscess,  but  whether 
the  symptoms  are  caused  by  the  tension  of  the  abscess  or  by  a 
more  acute  phase  of  the  disease  itself  is  not  always  clear. 

Large  abscesses  that  are  increasing  in  size  and  approaching 
the  surface  are  usually  accompanied  by  pain  and  by  elevation 
of  temperature.  This  may  indicate  a  slight  degree  of  secondary 
infection,  but  the  ordinary  deep  abscess  appears  to  have  no  other 
effect  than  to  add.  doubtless,  to  the  susceptibility  of  the  patient. 

The  Course  and  Peculiarities  of  Abscess  in  the  Different  Regions 
of  the  Spine. — The  tuberculous  abscess  may  remain  as  a  small 
collection  of  fluid  in  the  neighborhood  of  the  diseased  area.  As 
a  rule,  however,  it  slowly  mcreases  in  size,  and  under  the  influences 
of  the  force  of  gravity  and  the  tension  of  its  contents  it  finds  its 
way  down  the  spine  or  toward  the  exterior  of  the  body,  following 
the  path  of  least  resistance.  The  abscesses  that  have  passed  below 
the  diaphragm  or  that  have  originated  below  this  point  may  follow 
various  paths.  Some  enter  the  sheath  of  the  psoas  muscle,  and 
finally  make  their  appearance  on  the  inner  aspect  of  the  thigh, 
l)soas  abscess.  Others  perforate  the  sheath  of  the  quadratus 
liunborum  muscle  and  form  a  lumbar  abscess,  projecting  between 
the  twelfth  rib  and  the  crest  of  the  ilium  at  the  triangle  of  Petit. 
Those  abscesses  that  escape  from  the  fascia  of  the  psoas  muscle 
or  that  pass  downward  on  the  surface  of  the  iliac  fascia,  the  so- 
called  iliac  abscesses,  may  appear  as  a  tumor  over  the  outer  extremity 
of  Poupart's  ligament  at  the  junction  of  the  transversalis  and  iliac 
fasciae,  or  the  fluid  may  follow  the  course  of  the  iliac  artery  to  the 
thigh,  or,  escaping  from  the  greater  sacrosciatic  foramen,  form 
a  gluteal  abscess.  The  iliac  or  psoas  abscess  is  most  often  confined 
to  one  side,  but  it  may  be  bilateral,  the  two  sacs  communicating  with 
one  another  by  a  larger  or  smaller  channel. 

In  the  thoracic  region  the  abscess  may  remain  indefinitely  in 
the  posterior  mediastinum,  where,  if  large,  its  presence  may  be 
demonstrated  by  an  area  of  dulness  extending  toward  the  lateral 
region  of  the  thorax,  or  it  may  perforate  the  intercostal  muscles 
and  appear  on  the  posterior  or  lateral  aspect  of  the  chest,  or  it 


ABSCESS  IN  POTTS  DISEASE 


101 


may  pass  downward  through  the  aortic  opening  in  the  diaphragm 
and  become  an  ihac  abscess. 

Abscess  caused  by  disease  of  the  occipito-axoid  region  may  force 
its  way  forward  between  the  recti  muscles  and  appear  behind  the 
pharynx  as  the  retropharyngeal  abscess,  or  the  fluid  may  take 
the  opposite  direction  and  distend  the  suboccipital  triangle  and  then 
pass  forward  to  the  region  of  the  mastoid  process.  In  other  instances 
the  abscess  may  dissect  its  way  about  the  base  of  the  skull  or  pass 
upward  through  the  foramen  magnum  or  downward  into  the  spinal 
canal. 


Fig.  77. — Bilateral  lumbar  abscess. 


Abscesses  from  the  middle  cervical  region  usually  pass  outward 
between  the  scaleni  and  longus  colli  muscles  to  the  interval  between 
the  trapezius  and  sternomastoid,  perforating  the  skin  about  the 
middle  of  the  lateral  aspect  of  the  neck  near  the  anterior  border  of 
the  latter  muscle. 

These  are  the  paths  usually  followed  by  the  tuberculous  fluid, 
but  occasionally  it  may  enter  the  spinal  canal  or  break  into  the 
pleural  cavity  or  lung  or  intestine  or  by  the  side  of  the  rectum 
or  elsewhere. 

Treatment  of  Abscess. — Abscess  is  by  far  the  most  serious  com- 
plication of  Pott's  disease.     It  may  interfere  with  proper  mechani- 


102  TUBERCULOUS  DISEASE  OF  THE  SPINE 

cal  treatment,  and  it  is  often  a  cause  of  permanent  deformity. 
It  prolongs  the  course  of  the  disease  by  extending  its  boundaries, 
and,  although  it  is  not  often  an  immediate  cause  of  death,  yet 
many  patients  die  because  of  the  exhaustion  of  long-continued 
suppuration  and  of  the  amyloid  degeneration  that  may  finally 
result. 

A  large  abscess  is  always  a  source  of  danger  because  of  the  pos- 
sibility of  secondary  infection  of  its  contents  before  it  finds  an 
outlet,  and  because  of  the  probability  of  infection  when  a  communi- 
cation with  the  exterior  has  been  established.  Abscess  is,  however, 
a  s\Tnptom  and  result  of  disease,  and  in  properly  treated  cases  it 
is,  as  a  rule,  a  complication  of  comparatively  slight  consequence. 
If  it  is  not  present  when  treatment  is  begun,  one  may  hope  to 
prevent  it  by  effective  protection  of  the  spine;  and  if  it  is  present, 
this  protection  should  be  all  the  more  rigidly  enforced.  x\n  abscess 
often  exists  for  months  before  its  presence  is  detected,  and  after  its 
discovery  it  may  remain  quiescent  for  a  long  time,  and  finally 
disappear. 

In  a  large  proportion  of  cases  the  abscess  causes  no  symptoms, 
but  slowly  finds  its  way  to  the  surface  of  the  body.  ]Meanwhile 
it  may  be  assumed  that  the  disease  of  the  spine,  of  which  the  abscess 
is  a  result,  is  in  process  of  cure ;  so  that  when  the  fluid  finds  an  out- 
let the  source  of  supply  will  be  shut  off,  and  thus  the  patient  is 
spared  the  danger  and  discomfort  of  discharging  sinuses,  that  so 
often  persist  after  early  operation. 

The  so-called  radical  treatment  of  the  abscess  of  spinal  disease 
is  usually  unsatisfactory,  because  it  is  impossible  to  remove  the 
disease  of  which  the  abscess  is  a  s^Tuptom. 

As  the  abscess  is  a  s^Tuptom  of  disease,  so,  as  a  rule,  its  treat- 
ment should  be  s;sTnptomatic.  The  retropharyngeal  abscess  de- 
mands prompt  evacuation,  because  it  is  likely  to  obstruct  breath- 
ing and  swallowing,  because  its  sudden  rupture  may  cause  death, 
and  because  an  abscess  in  such  close  proximity  to  the  vital  centres 
is  always  a  source  of  danger.  In  cases  of  emergency  the  abscess 
may  be  evacuated  by  an  incision  in  the  middle  line  of  the  pharynx 
but  preferably  the  opening  should  be  from  the  exterior.  An  in- 
cision is  made  along  the  posterior  aspect  of  the  sternomastoid 
muscle  in  its  upper  third.  The  abscess  tumor  is  easily  reached  by 
careful  dissection,  and  drainage  is  established  which  has  evident 
advantages  over  that  into  the  throat. 

Abscesses  from  the  middle  cervical  region  usually  point  in  the 
lateral  region  of  the  neck  and  cause  but  little  inconvenience.  Ab- 
scesses in  the  upper  thoracic  region,  may  in  rare  instances,  cause 
dangerous  pressure  on  the  trachea  or  bronchi,  as  shown  by  spas- 
modic attacks  of  inspiratory  dyspnea,  "asthmatic  attacks."  In 
some  instances  an  area  of  dulness  near  the  seat  of  disease  demon- 
strates the  position  of  the  abscess,  but  if  it  lies  in  the  median  line 


ABSCBS.^  IN  POTT'S  DISEASE  103 

it  cannot  be  detected  either  by  auscultation  or  percussion.  If 
the  inspiratory  dyspnea  is  well-marked  the  symptom  may  be 
fairly  attributed  to  this  cause,  and  if  the  spasmodic  attacks  are 
frequent  and  severe  the  operation  of  costotransmrsectomy  is  indicated. 
An  incision  is  made,  preferably  on  the  right  side,  to  expose  the  artic- 
ulation between  the  transverse  process  and  the  rib,  and  one  or  two 
of  these  joints  is  resected;  the  finger  is  then  inserted  and  passed 
along  the  surface  of  the  adjacent  vertebral  body  until  the  abscess 
sac  is  reached.  This  is  usually  directly  in  front  of  the  spine  at  or 
about  the  fifth  dorsal  vertebra.  After  incision  a  drainage  tube 
should  be  inserted  (Fig.  9).  The  same  procedure  should  be  con- 
sidered whenever  abscess  and  paraplegia  are  combined,  as  it  is 
quite  possible  that  the  paralysis  is  dependent  on  the  pressure  of 
the  abscess.* 

In  the  lower  region  of  the  spine  intervention  may  be  indicated 
because  there  is  evidence  of  secondary  infection.  In  this  event  if 
the  abscess  distends  the  lumbar  region  or  forms  a  sac  on  either 
side  of  the  spine,  an  opening  in  the  loin  on  one  or  both  sides  of  the 
spine  is  necessary.  This  is  made,  as  in  operations  on  the  kidney, 
by  an  incision  on  the  outer  side  of  the  erector  spinse  muscle  between 
the  last  rib  and  the  crest  of  the  ilium  along  the  outer  border  of  the 
erector  spinse  muscles.  The  dense  fascia  is  divided,  exposing  the 
quadratus  lumborum  which  is  split  longitudinally  to  the  outer 
side  of  the  transverse  processes,  care  being  taken  to  avoid  the  lum- 
bar arteries.  In  certain  cases  it  is  possible  to  expose  the  spine  and 
to  remove  fragments  of  necrosed  bone  along  with  the  contents  of  the 
abscess.  As  a  rule  the  complete  removal  of  the  lining  membrane 
of  the  abscess  is  not  practicable,  and  one  must  be  content  to  evacuate 
the  solid  and  semisolid  contents  by  flushing  with  hot  water,  together 
with  as  much  of  the  abscess  membrane  as  may  be  removed  by  swab- 
bing with  gauze.  The  most  important  point  in  the  operation  is  to 
provide  efficient  and  complete  drainage  of  the  cavity.  Two  or 
more  counter- openings  are  usually  necessary  when  the  lumbar 
incision  has  been  made,  one  just  in  front  of  the  anterior  superior 
spine  and  another  in  the  thigh,  if  the  abscess  is  of  the  psoas  variety. 
Long  drainage  tubes  are  inserted,  and  should  remain  until  a  proper 
channel  for  the  escape  of  pus  has  been  established. 

If  the  abscess  is  of  one  side  only,  not  extending  into  the  thigh, 
and  if  evacuation  seems  advisable  because  of  its  size  or  tension, 
it  may  be  opened  by  an  anterior  incision  below  Poupart's  ligament 
just  to  the  inner  side  of  the  sartorius  muscle.  After  expression  of 
its  contents  a  drainage  tube  may  be  inserted  long  enough  to  reach 
to  the  seat  of  disease  if  it  be  of  the  lumbar  region. 

The  dressing  should  be  of  dry  sterile  gauze,  and  great  attention 
should  be  paid  to  absolute  cleanliness  and  to  effective  drainage. 
As  soon  as  it  is  possible,  if  the  discharge  has  become  slight  and  if 
the  spine  can  be  properly  supported,  the  patient  is  allowed  to  walk 


104  TUBERCULOUS  DISEASE  OF   THE  SPINE 

about  and  to  go  into  the  open  air.  In  ordinary  cases  a  slight 
discharge  persists  for  several  months  or  longer,  depending  on  the 
condition  of  the  disease. 

In  the  s^^Ilptomatic  treatment  of  abscess,  aspiratioii  is  sometimes 
of  service,  for  by  this  means  it  may  be  prevented  from  increasing 
in  size;  and  if  the  disease  is  quiescent,  the  cure  of  the  abscess  may 
follow  the  removal  of  its  contents  which  allows  the  collapse  of  its 
walls.  \Yhen  aspiration  is  employed  it  should  be  repeated  systemati- 
cally as  often  as  the  abscess  cavity  refills.  After  each  evacuation 
pressure  should  be  applied  to  favor  the  adhesion  of  the  apposed 
walls.  - 

If  the  contents  are  of  such  a  nature  that  aspiration  is  ineffec- 
tive an  incision  may  be  made,  through  which  the  semisolid  sub- 
stance may  be  removed.  The  opening  is  then  closed  by  several 
layers  of  sutures,  and  pressure  is  applied  with  the  aim  of  obtain- 
ing primary  union.  This  operation  may  be  repeated  several  times 
if  necessary.  Often  a  sinus  eventually  forms  at  one  or  other  of 
the  openings. 

The  injection  of  antituhoxulous  remedies,  although  they  may 
have  no  direct  influence  on  the  disease,  may  diminish  the  infec- 
tive quality  of  the  fluid  and  solid  contents  of  the  abscess  and 
stimulate  the  reparative  processes  that  check  its  progress.  An 
emulsion  of  iodoform  in  sterilized  oil  or  glycerin  (10  to  20  per  cent.) 
is  often  used.  This,  m  doses  of  from  4  to  30  grams,  is  injected  at 
intervals  of  from  two  to  four  weeks,  after  evacuation  of  the  con- 
tents; the  amount  and  the  frequency  of  the  injection  depending 
upon  the  age  of  the  patient  and  upon  the  eft'ect  of  the  treatment. 
If  used  with  caution  as  to  asepsis,  and  to  the  toleration  of  the  patient 
for  iodoform,  no  harm  will  follow,  even  if  the  treatment  proves 
to  be  of  little  practical  value. 

Calot  favors  frequent  aspirations  usually  at  intervals  of  a  week 
or  more  and  injection  of  a  fluid  composed  of: 

Grams. 

Sterilized  oil 70 

Ether 30 

Creosote 6 

Iodoform 10 

2  to  12  grams  are  injected,  according  to  the  age  of  the  child. 

The  abscess  is  aspirated  as  often  as  pus  accumulates  and  the 
average  munber  of  injections  is  10-12.  \Mien  the  fluid  with- 
drawn becomes  serous  in  character  the  injections  are  discontinued. 

As  the  abscess  approaches  the  surface  the  skin  becomes  red 
and  thm,  and  there  is  usually  some  local  sensitiveness  and  pain. 
Whenever  spontaneous  evacuation  of  the  abscess  is  probable  the 
mother  should  be  instructed  as  to  the  necessity  of  absolute  clean- 
liness, and  the  proper  dressings  should  be  provided.  In  such  an 
event  the  patient  should  remain  in  bed  for  several  days,  or  un  il 
the  discharge  has  become  small  in  amount. 


PARALYSIS  IN   POTT'S  DISEASE  105 

In  the  symptomatic  treatment  of  the  abscesses  of  Pott's  disease 
one  may  conclude,  then,  that  operation  will  be' indicated  in  the 
treatment  of  the  retropharyngeal  abscess  and  in  the  rare  instances 
when  dangerous  pressure  is  exerted  by  an  abscess  in  the  posterior 
mediastinum.  It  is  indicated,  of  course,  when  there  is  evidence 
of  mixed  infection  or  when  the  rapidly  enlarging  abscess  causes 
discomfort  or  interferes  with  effective  support.  It  is  usually  indi- 
cated when  the  abscess  is  of  large  size  if  proper  care  can  be  pro- 
vided. The  operative  treatment  is  practically  free  from  danger 
if  cleanliness  and  efficient  drainage  can  be  assured.  Aspiration  is 
free  from  danger;  it  is  often  of  service  in  preventing  the  enlarge- 
ment of  the  abscess,  and  it  may  hasten  its  absorption.  An  incision 
for  the  complete  removal  of  the  contents,  followed  by  immediate 
closure  of  the  wound,  is  in  many  instances  the  operation  of 
selection. 

If  the  abscess  cavity  after  the  removal  of  its  contents  is  not 
large,  it  may  be  filled  with  Beck's  mixture  of  bismuth  and  vase- 
line 1-3,  injected  at  a  temperature  of  110°.  This  treatment  is 
described  in  Chapter  V.  In  all  cases  of  this  type  constitutional 
treatment  particularly  exposure  to  the  direct  rays  of  the  sun 
is  of  the  greatest  importance. 

Paralysis  Complicating  Pott's  Disease  ("Pott's  Paraplegia"). — 
The  tuberculous  process  in  the  vertebral  bodies  may  extend  back- 
ward, and  breaking  through  the  posterior  ligment  it  may  enter  the 
epidural  space  and  press  upon  the  spinal  cord ;  then  follows  paresis 
or  paralysis  of  the  parts  below  the  constriction. 

The  calibre  of  the  spinal  canal  is  not  usually  lessened  by  the 
characteristic  angular  distortion  of  the  spine,  although  the  weight 
and  forward  inclination  of  the  trunk  may  force  the  softened  tissues 
backward  against  the  cord  and  thus  increase  the  direct  pressure. 
In  fact,  paralysis  is  much  more  often  associated  with  a  slight  or 
moderate  kyphosis  than  with  extreme  deformity. 

In  rare  instances  the  pressure  may  be  due  to  a  fragment  of 
necrosed  bone  or  to  solidification  of  the  tissues  in  and  about  the 
canal  during  the  process  of  repair.  It  may  be  caused,  in  part, 
at  least,  by  the  pressure  of  a  neighboring  abscess,  but  it  is  usually 
the  result  of  the  slow  advance  of  the  tuberculous  disease.  When 
this  has  forced  an  entrance  into  the  spinal  canal  it  sets  up  a  resist- 
ant inflammatory  thickening  of  the  coverings  of  the  cord — first 
a  peripachymeningitis  and  then  a  pachymeningitis.  In  addition 
to  the  direct  pressure,  there  may  be  an  interference  with  blood  supply 
and  the  lymphatic  circulation,  with  resulting  local  edema  of  the 
cord.  An  increase  in  the  interstitial  connective  tissue  of  its  sub- 
stance and  a  corresponding  atrophy  of  the  nervous  elements  may 
follow,  and  as  a  sequence  an  ascending  and  descending  degeneration 
that,  in  prolonged  cases,  may  terminate  in  partial  or  complete 
sclerosis.     The   dura   mater   is  a   resistant   structure,  and  direct 


106  TUBERCULOUS  DISEASE  OF   THE  SPINE 

destruction  of  the  cord  by  the  tuberculous  disease  is  rare.  In 
fact,  as  a  rule,  but  little  permanent  damage  results,  even  from  long- 
continued  pressure  and  paralysis,  for  the  cord  seems  in  these  cases 
to  possess  the  power  of  repair  and  regeneration  to  a  remarkable 
degree. 

Frequency. — In  1670  cases  of  Pott's  disease  recorded  at  the 
New  York  Orthopedic  Dispensary,  paralysis  occurred  in  218,^ 
and  in  445  cases  in  the  private  practice  of  Dr.  C.  F.  Taylor,^  59 
cases  of  paralysis  were  observed.  Thus,  in  a  total  of  2015  cases 
of  Pott's  disease  there  were  279  cases  of  paralysis,  or  13.7  per  cent. 

This  proportion  is  much  larger  than  the  normal,  however,  for 
many  of  the  patients  were  taken  to  the  special  hospital  because  of 
the  paralysis,  as  in  40  of  Taylor's  and  in  133  of  the  dispensary 
cases.  If  these  be  excluded,  the  percentage  of  paralysis  occurring 
in  those  actually  under  treatment  is  reduced  to  5.6  per  cent.  This 
percentage  corresponds  very  closely  to  that  of  Dollinger,^  viz.,  41 
cases  of  paralysis  in  700  cases  of  Pott's  disease  under  treatment 
(5.8  per  cent.),  and  it  may  be  accepted  as  representing  the  average 
liability  to  paralysis  among  those  who  have  received  treatment  for 
Pott'  disease,  the  percentage  being  much  higher  in  neglected  cases. 
In  241  cases  of  Pott's  disease  in  adolescents  and  adults  treated  by 
Painter ,''  there  were  33  cases  (13  per  cent.),  a  higher  proportion 
than  in  childhood. 

The  Liability  to  Paralysis  in  Disease  of  the  Different  Regions  of 
the  Spine. — The  liability  to  paralysis  is  very  much  greater  in  dis- 
ease of  certain  regions  of  the  spine  than  in  others. 

Thus,  105  of  the  209  cases  in  ]\Iyers's  list,  in  which  the  situation 
of  the  disease  was  recorded,  complicated  disease  of  the  dorsal  region 
above  the  eighth  vertebra.  Of  the  remainder,  in  16  the  disease  was 
of  the  cervical  region;  in  12  of  the  cervicodorsal,  and  in  59  of  the 
lower  dorsal  and  dorsolumbar  regions. 

Thirty-seven  of  Taylor's  59  cases  were  caused  by  disease  of  the 
dorsal  region;  8  occurred  in  the  cervical  and  cervicodorsal  and  11 
in  the  dorsolumbar  and  hunbar  regions. 

Twenty-six  of  the  total  of  41  cases  recorded  by  Dollinger  were 
caused  by  disease  of  the  third  to  the  seventh  dorsal  vertebrae, 
inclusive,  or  about  23  per  cent,  of  the  cases  in  which  this  region 
was  involved. 

Of  132  cases  of  paraplegia  reported  by  Gibney^  not  one  com- 
plicated lumbar  disease;  nearly  all  were  caused  by  compression 
in  the  middle  or  upper  thoracic  region. 

These  statistics  show  that  the  upper  and  middle  dorsal  sec- 

1  Myers:  Tr.  Am.  Orthop.  Assn.,  1891,  iii,  209. 

-  Taylor  and  Lovett:  New  York  Med.  Rec,  June  19,  1896. 

^  Loc.  cit. 

*  Am.  Jour.  Orthop.  Surg.,  November,  1910. 

*  Jour.  Nerv.  and  Ment.  Dis.,  January  5.   1897. 


PARALYSIS  IN  POTT'S  DISEASE  107 

tion  is  the  point  of  greatest  liability  to  paralysis — a  fact  that  is 
explained  possibly  by  the  smaller  size  of  the  canal  at  this  point, 
and  by  the  difficulty  of  assuring  complete  fixation  at  the  seat  of 
disease.  It  may  be  estimated  that  in  15  per  cent,  of  the  cases 
of  Pott's  disease  of  this  region  paralysis  will  appear  before  cure 
is  established. 

Time  of  Onset. — In  exceptional  cases  the  paralysis  may  pre- 
cede deformity,  and  it  may  be  the  first  symptom  that  attracts 
attention  to  the  disease.  In  14  of  74  cases  reported  by  Gibney 
the  paralysis  was  present  when  the  bone  disease  was  recognized, 
but  it  is  probable  that  the  primary  disease  had  existed  for  several 
months  before  the  appearance  of  the  paralysis.  Usually  it  is  a 
comparatively  late  symptom,  appearing  after  the  stage  of  deformity 
and  more  often  six  to  twelve  months  after  the  recognition  of  the 
disease,  but  its  appearance  may  be  deferred  until  long  after 
apparent  cure. 

Duration. — In  exceptional  cases  the  paralysis  appears  to  be  caused 
simply  by  disturbance  of  the  circulation  of  the  cord,  due  possibly 
to  the  pressure  of  the  superincumbent  weight  upon  the  softened 
and  diseased  tissues,  as  it  disappears  almost  immediately  when 
the  spine  is  straightened  and  supported.  Usually  the  paralysis 
persists  for  several  months,  not  infrequently  it  lasts  a  year,  and  par- 
tial or  even  complete  recovery  is  possible  after  a  much  longer  time, 
in  one  instance  after  five  years. ^  Recovery  from  the  paralysis  de- 
pends upon  the  course  of  the  disease  of  which  it  is  a  symptom, 
upon  the  absorption  and  organization  of  the  tuberculous  granu- 
lations that  press  upon  the  cord,  and  upon  the  regenerative  changes 
in  its  structure,  if  it  has  been  implicated  in  the  disease. 

Symptoms. — The  most  marked  effect  of  the  pressure  on  the  cord 
is  the  interference  with  its  conductivity.  The  reflex  centres  situ- 
ated below  the  point  of  constriction,  relieved  from  the  inhibition 
of  the  brain,  become  overactive,  while  control  of  the  parts 
below  the  constriction  is  lessened  or  lost.  The  pressure  of  the 
diseased  products  is  more  directly  upon  the  anterolateral  columns, 
so  that  motion  is  much  more  often  primarily  affected  than  is 
sensation. 

The  early  symptoms  of  Pott's  paraplegia,  are  weakness,  awk- 
wardness, and  a  stumbling,  shambling  gait.  The  symptoms 
usually  increase  rapidly  until  paralysis  of  motion  is  complete. 
At  this  stage  the  patella  tendon  reflex  is  increased,  and  ankle- 
clonus  is  often  present.  As  a  rule  both  limbs  are  affected  in  equal 
degree,  but  occasionally  paralysis  of  one  may  be  more  complete 
or  may  precede  that  of  the  other,  and  in  the  stage  of  recovery 
power  may  return  more  rapidly  on  one  side  than  on  the  other. 
The  limbs  in  the  early  stage  of  the  paralysis  may  appear  limp  and 

1  Goldthwait:  Am.  Jour.  Orthop.  Surg.,  April,  1915. 


108  TUBERCULOUS  DISEASE  OF   THE  SPINE 

powerless,  but  when  the  patient  is  moved  or  when  the  reflexes  are 
stimulated  the  peculiar  spastic  rigidity  or  stiffness  appears. 

As  a  rule  the  stiffness  increases  with  the  duration  of  the  dis- 
ease, and  spastic  contractions  are  often  present;  thus,  the  thighs 
may  be  apposed,  the  knees  flexed,  and  the  feet  extended. 
Persistent  contractions  indicate,  as  a  rule,  permanent  damage  to 
the  cord,  and  in  such  cases  complete  recovery  is  unusual. 

Sensation  is  not  affected  ordinarily,  but  in  the  more  severe  or 
prolonged  cases  it  may  be  impaired  or  lost.  Sensation  was  retained 
throughout  in  2-4  of  the  40  cases  reported  by  Shaffer. 

In  the  cases  of  partial  paralysis  control  of  the  bladder  may  be 
retained,  but  usually  there  is  incontinence.  As  the  bladder  fills 
the  reflex  centre  is  excited,  and  it  empties  itself. 

The  control  of  the  sphincter  ani  is  less  often  or  less  noticeably 
affected. 


Fig.  78. — Pott's  paraplegia  before  the  stage  of  deformitj'.    The  apparatus  used  in  the 
treatment  of  this  case  is  shown  in  Fig.  47. 

i^s  the  paralysis  is  the  result  in  many  instances  of  active  or  of 
advancing  disease  its  onset  may  be  preceded  by  discomfort  or 
pain.  Thus,  noticeable  discomfort  attended  by  an  exaggeration 
of  the  patella  tendon  reflex  may  be  considered  as  an  indication 
for  enforced  rest  of  the  individual,  although  increased  activity 
of  the  reflexes  is  not  uncommon  during  the  progressive  stage  of 
the  disease  without  apparent  involvement  of  the  spinal  cord.  When 
paralysis  occurs  in  patients  who  are  under  treatment  for  Pott's 
disease  the  onset  is  not  attended,  as  a  rule,  by  noticeable  or  unusual 
pain;  nor  is  pain  usually  complained  of  after  the  paralysis  has 
developed. 

The  extent  of  the  paralysis  depends  upon  the  situation  of  the 
disease.  In  exceptional  cases,  in  which  the  cervical  enlargement, 
from  the  fifth  cervical  to  the  first  dorsal  is  involved,  there  may  be 
flaccid  paralysis  of  the  arms  with  spastic  paralysis  of  the  lower 
extremities.  This  occurred  in  7  of  the  cases  reported  by  iNIyers. 
As  a  rule,  however,  the  paralysis  is  a  complication  of  disease  of  the 


PARALYSIS  IN  POTT'S  DISEASE  109 

dorsal  region  above  the  reflex  centres  in  the  lumbar  enlargement 
of  the  cord  but  below  the  nerve  supply  of  the  upper  extremities. 
If  the  disease  is  at  a  lower  point,  for  example,  in  the  dorsolumbar 
section  so  that  these  reflex  centres  themselves  are  directly  imph- 
cated,  reflex  activity  is  not  increased,  and  intermittent  incon- 
tinence is  replaced  by  constant  dribbling  of  urine.  If  the  cauda 
equina  alone  is  implicated  in  disease  of  the  lumbosacral  region  the 
symptoms  are  those  of  neuritis,  pain,  numbness,  and  weakness  in 
the  area  supplied  by  the  afl^ected  nerves.  Such  weakness  with  ac- 
companying muscular  atrophy  may  be  present  in  the  upper  ex- 
tremities when  the  disease  is  in  the  neighborhood  of  the  origin 
of  the  brachial  plexus,  while  in  the  lower  limbs  the  characteristic 
spastic  coHdition  is  evident. 

In  characteristic  cases  the  nutrition  of  the  limbs  is  not 
greatly  affected,  nor  do  the  contractions  become  permanent; 
but  when  the  paralysis  is  prolonged,  and  particularly  when 
sensation  is  lost,  the  muscles  waste,  the  circulation  is  impaired,  and 
fixed  distortions  usually  appear.  Even  in  the  more  prolonged  and 
severe  forms  of  paralysis  occurring  in  childhood  bed-sores  are  rarely 
seen. 

Prognosis. — In  properly  treated  cases  the  prognosis  is  very 
favorable,  as  is  illustrated  by  the  final  results  of  47  of  the  59  cases 
of  paraplegia  in  Taylor's  practice.  Of  these  39  recovered  com- 
pletely, 5  died  of  intercurrent  disease  while  apparently  recovering, 
and  in  3  the  recovery  was  partial. 

Of  the  hospital  cases  recorded  by  Myers,  3  per  cent,  died  of 
intercurrent  disease.  The  final  results  could  be  ascertained  in 
but  55  per  cent,  of  the  patients.     All  of  these  recovered. 

Of  74  cases  of  paraplegia  treated  by  Gibney,^  45  were  cured, 
12  improved,  8  unimproved,  and  9  died.  Thus,  77  per  cent, 
were  cured  or  improved.  In  a  similar  series  of  40  cases  reported 
by  Shaffer,  80  per  cent,  were  cured  and  but  10  per  cent,  of  the 
remainder  were^considered  as  hopeless  cases. 

In  a  total  of  975  cases  "abandoned  to  medical  treatment," 
collected  from  various  sources  by  Rozoy,^  there  were  429  cures. 
Of  the  remainder  16  were  improved,  130  were  unimproved,  and 
there  were  244  deaths.  The  contrast  in  the  results  reported  would 
appear  to  show  the  advantage  of  thorough  mechanical  treatment. 

Recurrence  of  paralysis  after  recovery  is  not  infrequent;  in 
18  cases  such  recurrences  from  one  to  four  times  are  recorded 
by  Myers,  and  seven  successive  attacks  of  paralysis  were  observed 
in  a  patient  under  treatment  at  the  Hospital  for  Ruptured  and 
Crippled. 

The  relapses  are  due  apparently  to  the  renewed  activity  of 

1  Jour.  Nerv.  and  Ment.  Dis.,  January  5,  1897. 

2  Mai.  de  Pott,  Paris,  1901. 


110  TUBERCULOUS  DISEASE  OF   THE  SPINE 

the  disease,  and  in  many  instances  this  may  be  explained  by  the 
neglect  of  protective  treatment. 

Treatment. — The  treatment  of  the  paralysis  is  included  in  the 
treatment  of  the  disease  of  which  it  is  a  symptom,  except  that 
even  greater  care  should  be  exercised  to  assure  fixation  of  the 
spine. 

Rest  in  the  position  of  hyperextension  on  the  stretcher  frame 
is  indicated.  Direct  traction  by  the  weight  and  pulley  may  be 
used  if  the  disease  is  in  the  upper  dorsal  or  cervical  regions.  For 
bed-ridden  patients  a  convenient  method  of  assuring  extension 
of  the  spine  in  connection  with  head  traction  is  to  suspend  the 
trunk  on  a  sling  of  canvas  drawn  transversely  beneath  the  seat 
of  disease  and  attached  to  bars  on  the  sides  of  the  bed  after  the 
Rauchfuss  method.  The  back  brace  or  the  plaster  jacket  assures 
additional  fixation,  and  such  support  should  be  employed  in  con- 
nection with  recurrency  whenever  practicable.  The  Calot  jacket 
with  the  greater  fixation  assured  by  the  pressure  over  the  kyphosis 
should  be  employed  in  preference  to  other  supports  of  this  char- 
acter. If,  however,  the  brace  has  been  worn  as  an  ambulatory 
support,  its  shape  must  be  modified  to  accommodate  the  change 
in  the  outline  of  the  spine,  induced  by  recumbency  and  extension. 

Manipulation  or  massage  of  the  limbs  is  contra-indicated 
because  it  simulates  the  reflexes.  If  persistent  contractions  of 
the  muscles  are  present  the  deformity  may  be  reduced  by  trac- 
tion applied  in  the  ordinary  manner  (Fig.  33),  or  a  fixation  brace 
may  be  worn.  A  long  double  spica  plaster  support  of  which  the 
upper  part  is  cut  away  to  permit  inspection  is  a  satisfactory 
treatment  if  the  contractions  are  spasmodic  and  painful. 

Counter-irritation  at  the  seat  of  disease  was  by  Pott  con- 
sidered of  the  greatest  value,  and  the  application  of  the  actual 
cautery  from  time  to  time,  about  the  kyphosis,  seems  in  certain 
cases  to  exert  a  favorable  influence  on  the  underlying  disease. 

Electricity,  particularly  galvanism,  has  been  used,  and  it  is  of 
some  service  in  preserving  the  nutrition  of  the  limbs.  Its  value 
in  a  case  must  be  judged  by  its  effect. 

Internal  remedies  are  of  little  value  with  the  possible  excep- 
tion of  iodide  of  potassium,  which  is  supposed  to  act  upon  the 
tuberculous  granulation  tissue  as  upon  the  products  of  syphilitic 
disease.  A  convenient  method  of  administration  is  a  solution  of 
which  one  drop  represents  one  grain  of  the  drug.  This  is  given 
in  milk  or  in  Vichy  water,  beginning  with  five  drops  three  times 
daily  and  increasing  the  dose  a  drop  each  day  until  the  point  of 
toleration  is  reached. 

The  first  indication  of  improvement  is  usually  lessening  of  the 
muscular  spasm;  then  the  abflity  to  move  a  toe  may  be  regained, 
after  which  recovery,  foflows  quickly.  At  this  stage  massage  of 
the  limbs  may  be  employed  with  advantage.      The   exaggerated 


PARALYSIS  IN  POTT'S  DISEASE  111 

reflexes  may  persist  long  after  recovery;  in  fact,  as  has  been  stated, 
this  symptom  is  not  uncommon  among  patients  suffering  from 
dorsal  Pott's  disease  who  have  never  been  paralyzed. 

Laminectomy. — The  operation  of  laminectomy  was  at  one  time 
in  favor,  but  it  has  now  been  practically  abandoned,  as  a  treatment 
of  routine  at  least,  for  the  paraplegia  of  Pott's  disease,  because 
it  has  been  proved  that  recovery,  if  somewhat  long  deferred,  is 
the  rule  without  operation,  while  the  direct  death-rate  of  the  opera- 
tion is  large.  Of  132  operations  reported  by  Menne,^  56  per  cent, 
of  the  patients  were  cured  or  improved. 

In  134  cases  collected  by  Rhein^  the  immediate  mortality  (those 
dying  within  a  month  after  the  operation)  was  36  per  cent. 

Lloyd''  has  collected  128  "reliable"  cases  of  Pott's  disease  in 
which  laminectomy  was  performed.  The  deaths  due  directly 
to  the  operation  were  21    (16.45  per  cent.);  subsequent  deaths, 

36  (28.20  per  cent.) ;  total  deaths,  57  (44.55  per  cent.) ;  recoveries, 

37  (28  per  cent.);  improved,  16  (12.5  per  cent.);  unimproved,  18 
(14.06  per  cent.).  Of  8  cases  operated  by  Trendelenburg  in  1889 
6  were  living  and  well  in  1905.     One  was  unimproved.^ 

Laminectomy  is  an  incomplete  operation  in  the  sense  that  the 
disease  of  the  bone  is  not  removed,  thus  recurrence  of  paralysis 
from  extension  of  the  disease  is  not  infrequent  after  a  successful 
immediate  result.  It  should  be  reserved  for  those  cases  in  which 
after  a  thorough  and  prolonged  trial  of  ordinary  methods  the  con- 
dition does  not  improve.  Eighteen  months  has  been  suggested 
as  the  proper  time  in  which  to  test  conservative  treatment.  The 
operation  may  be  indicated  also  if  the  symptoms,  in  spite  of  treat- 
ment, increase  in  severity,  particularly  when  the  cervical  region 
is  involved  or  when  there  is  evidence  that  the  integrity  of  the  cord 
is  threatened,  or  when  the  paralysis  is  of  sudden  onset,  or  when 
displacement  of  bone  or  pressure  from  an  abscess  seems  probable 
as  the  exciting  cause,  although  in  the  latter  instance  the  direct 
evacuation  of  the  abscess  by  costotransversectomy,  as  advocated  by 
Menard,  should  precede  laminectomy.  Occasionally  the  operation 
is  indicated  as  a  forlorn  hope  in  adults  suffering  from  cystitis  and 
bed-sores. 

The  usual  method  in  operating  is  as  follows:^  A  long  incision 
is  made  parallel  to  and  close  by  the  side  of  the  spinous  processes. 
The  muscles  are  drawn  to  one  side,  the  spinous  processes  are  cut 
through  and  drawn  with  the  attached  muscles  to  the  opposite  side, 

1  Ztschr.  f.  Orthop.  Chir.,  1912,  iv, 

2  Willard:     Jour.  Nerv.  and  Ment.  Dis.,  May,  1897. 

3  Philadelphia  Med.  Jour.,  February  22,   1902. 
^  Sultan:     Ztschr.  f.  Chir.,  Ixxviii,  1  and  2. 

*  It  should  be  borne  in  mind  that  the  segments  of  the  cord  do  not  correspond  to 
the  spinous  processes  of  the  same  number.  Thus,  in  the  cervical  region  the  affected 
segment  is  one  vertebra  higher.  In  the  upper  dorsal  region  two  higher.  From  the 
sixth  to  eleventh  dorsal  three  higher.  The  three  lower  lumbar  and  sacral  segments 
are  to  be  found  opposite  the  eleventh  and  twelfth  dorsal  spines.     (Chipault.) 


112  TUBERCULOUS  DISEASE  OF   THE  SPINE 

The  laminse  at  the  seat  of  disease  are  then  removed  with  the  cutting 
forceps,  exposing  the  dura  mater.  The  tuberculous  tissue  is  usually 
found  upon  the  front  or  lateral  surfaces  of  the  canal,  and  its  complete 
removal  is  often  impossible  and  the  operation  is  usually  conducted 
with  the  purpose  of  simply  relieving  pressure.  The  shock  of  the 
operation  is  often  marked,  so  that  it  should  be  as  rapid  as  possible, 
and  loss  of  blood  should  be  carefully  guarded  against.  As  a  rule 
the  wound  may  be  closed  without  drainage.  After  the  operation 
the  spine  should  be  supported  by  the  brace  or  jacket  until  the 
disease  is  cured. 

In  several  instances  forcible  correction  of  the  spine  (Calot's  opera- 
tion) relieved  the  pressure  on  the  cord  and  rapid  recovery  followed. 
This  indicates  the  importance  of  assuring  overextension  of  the  spine 
whenever  it  is  possible,  but  this  should  be  attained  preferably  by 
gradual,  postural  correction  rather  than  by  force. 

Fortunately  the  great  majority  of  cases  of  paraplegia  from 
Pott's  disease  occur  in  childhood,  and,  as  has  been  mentioned, 
the  complications  of  later  life,  bed-sores,  cystitis,  and  the  like,  are 
rarely  troublesome.  Such  paralysis  in  the  adult  is  more  serious 
from  every  point  of  view.  The  principles  of  treatment  are  the 
same,  but  their  application  is  more  difficult  and  the  prognosis  is 
more  doubtful. 

Local  Paralysis  Complicating  Pott's  Disease. — In  certain  cases 
the  extension  of  the  disease  may  involve  the  nerve  roots  near  their 
exit  from  the  spine.  Actual  compression  at  the  intervertebral 
foramina  is  unusual  since  the  nerves  are  embedded  in  fat  and  occupy 
but  one-third  of  the  space.  Local  paralysis  may  occur  independently 
of  the  involvement  of  the  cord.  The  symptoms  are  those  of  neu- 
ritis in  the  affected  nerves.  In  extremely  rare  instances  the  pres- 
sure on  the  cord  may  cause  hemiplegia. 

The  Operative  Treatment  of  Pott's  Disease. — It  has  long  been 
known  that  the  cure  of  Pott's  disease  is  often  aided  by  the  fusion  of 
the  posterior  or  unaffected  part  of  the  spine,  and  that  anchylosis 
here  sometimes  precedes  that  at  the  seat  of  the  disease. 

From  time  to  time  attempts  have  been  made  to  induce  such 
fixation  by  operation,  one  of  the  earliest  being  that  of  Hadra  by 
wiring  of  the  spinous  processes.^ 

In  1910  F.  Lange-  reported  a  case  in  which  cure  was  hastened  by 
the  insertion  of  metal  rods  beneath  the  muscles  on  either  side  of  the 
spinous  processes  at  the  seat  of  the  disease.  He  suggested  also 
the  use  of  transplanted  bone  for  the  same  purpose. 

The  first  of  the  effective  operations  for  inducing  anchylosis  is  that 
of  R.  A.  Hibbs,^  by  removal  of  the  periosteum  from  the  spines  and 


1  Tr.  Am.  Orthop.  Assn.,  1891,  iv. 

-  JahresktLTse  f.  artz.  Forth.,  vSeptember,   1910. 

3  New  York  Med.  Jour.,  May  27,  1911. 


OPERATIVE  TREATMENT 


113 


6Th. 


Fig.  79. — Spinous    processes    partially    fractured    and    used    for    bridging    tlie    gap 
between  the  vertebrae.      (Hibbs.) 


114  TUBERCULOUS  DISEASE  OF   THE  SPINE 

laminae  and  breaking  down  the  spinous  processes.  This  operation 
is  described  by  Hibbs  as  follows:^ 

A  longitudinal  incision  is  made  directly  over  the  spinous  processes, 
through  the  skin,  supraspinous  ligament  and  periosteum,  to  the  tips 
of  the  spinous  processes.  The  periosteum  is  split  over  both  the 
upper  and  lower  borders  of  the  spinous  processes  and  the  laminae, 
and  stripped  back  from  them  to  the  base  of  the  transverse  processes. 
The  spinous  processes  are  then  transposed  after  partial  fracture,  so 
that  they  make  contact  with  fresh  bone,  the  base  of  each  with  its 
own  base  and  the  tips  with  the  base  of  the  next  below.  The  adja- 
cent edges  of  the  laminae  being  absolutely  free  from  periosteum,  a 
small  piece  of  bone  is  elevated  from  the  edge  of  the  laminte  and  placed 
across  the  space  between  them,  its  free  end  in  contact  with  the  bare 
bone  of  the  laminae  next  below  it; 

The  number  of  vertebrae  in  each  instance  included  in  the  operation 
is  determined  by  the  extent  of  the  disease.  It  is  necessary  always 
to  be  sure  of  attaching  the  diseased  vertebrae  at  either  end  of  the 
involved  area  to  healthy  ones  above  and  below. 

The  lateral  walls  of  periosteum  and  the  split  supraspinous  liga- 
ment are  brought  together  over  these  processes  by  interrupted 
chromic  catgut  sutures.  The  skin  wound  is  closed  by  silk,  and  a 
steel  brace  applied,  with  the  space  between  the  uprights  increased 
somewhat^at  the^site  of  the  wound,  so  as  not  to  make  pressure  on 
it.  In  some  cases  the  gaps  in  the  periosteum  removed  from  the 
spinous  processes  and  laminae  have  been  closed  by  suture,  thus 
establishing  at  once  a  continuous  periosteal  wall,  but  this  is  of 
doubtful  utility. 

Rest  in  bed  is  absolute  for  from  eight  to  ten  weeks.  During  the 
next  four  weeks,  sitting  up  is  permitted.  At  the  end  of  the  twelfth 
week,  walking  is  allowed.  The  brace  is  continued  for  another 
month,  when  it  is  removed  for  a  part  of  each  day  until  gradually 
left  off  entirely.  With  children  under  five  it  should  be  worn  for 
six  months. 

In  a  later  paper  it  is  stated  that  the  operation  has  been  slightly 
modified  in  that  it  now  includes  arthrodesis  of  the  articular  joints. 
One  hundred  and  fifty  cases  are  reported  with  146  successes  and  no 
deaths.  In  a  recent  discussion  Hibbs  has  stated  that  support  of 
the  spine  should  be  continued  for  from  6-18  months,  the  opera- 
tion being  distinctly  an  adjunct  to  conservative  treatment.  He 
reports  350  cases  without  mortality.^ 

The  alternative  operation,  one  of  bone  transplantation,  was 
described  by  F.  H.  Albee,^  in  September  of  the  same  year.  This 
has  been  slightly  modified  since  and  is  now  essentially  as  follows: 
A  lateral  incision  is  made  by  the  side  of  the  spinous  processes, 

1  Jour.  Am.  Med.  Assn.,  August  10,  1912. 

2  Am.  Med.  Assn.,  January  20,  1917. 

^  Jour.  Am.  Med.  Assn.,  September  8,  1911. 


OPERATIVE   TREATMENT  115 

extending  above  and  below  the  seat  of  disease.  The  flap  is  retracted, 
exposing  the  spinous  processes,  over  which  an  incision  is  made 
dividing  the  interspinous  Hgament  in  the  middle  line.  With  a  thin 
chisel  the  spinous  processes  are  split,  including  two  of  those  of 
the  healthy  vertebrse  above  and  below,  if  the  disease  is  of  the  tho- 
racic region,  or  but  one  if  in  the  lumbar;  the  halves  on  one  side  are 
separated  laterally,  leaving  a  trough,  into  which  a  section  of  the 
crest  of  the  tibia  of  sufficient  length,  the  endosteal  side  apposed  to 
the  median  halves  of  the  spines,  is  inserted  and  fixed  in  place  by 
strong  sutures  of  kangaroo  tendon  passed  through  the  interspinous 
ligament.  The  other  tissues  are  then  closed  in  layers.  A  plaster 
splint  or  jacket  may  be  applied,  or  the  patient  may  be  placed  on  a 
stretcher  frame,  or  in  suitable  cases,  simply  confined  to  the  bed. 
According  to  Albee,  consolidation  is  often  complete  in  six  to  eight 
weeks  when  ambulation  is  then  tentatively  resumed,  and  in  favor- 
able cases  no  support  is  applied  because  a  certain  strain  is  supposed 
to  strengthen  the  graft. 

In  most  instances  the  transplant  must  be  adjusted  to  a  more  or 
less  angular  deformity,  either- by  making  multiple  cuts  with  the  saw 
on  its  under  surface,  so  that  it  may  be  bent  as  a  carpenter  bends  a 
board.  Or,  by  cutting  a  section  from  the  inner  side  of  the  tibia 
corresponding  to  the  contour  of  the  curve.  In  cases  of  extreme 
deformity  the  graft  may  be  divided  into  several  overlapping  sec- 
tions which  eventually  become  fused  in  the  process  of  repair. 

In  a  recent  communication^  Albee  reports  178  cases.  Rethinks 
the  operation  indicated  in  all  cases  attended  by  pain  or  muscular 
spasm,  without  regard  to  age  or  the  situation  of  the  disease,  the 
only  contra-indication  being  the  presence  of  suppurating  sinuses. 

Assuming  that  these  operations  are  equally  effective,  that  of  Hibbs 
has  the  advantage  that  it  does  not  involve  other  injury,  that  it 
reduces  in  some  degree  the  angularity  of  the  projection  and  that  it 
is  more  applicable  to  cases  of  extreme  deformity.  On  the  other 
hand,  it  is  a  tedious  operation,  involving  m-ore  local  disturbance 
of  the  tissues. 

Bone  transplantation  has  the  advantage  of  providing  immediate 
support  with  possibly  greater  assurance  of  permanent  security 
with  very  little  local  injury. 

In  the  one  instance,  the  transplanted  bone  and  the  resulting 
fusion  of  the  spinous  processes  form  a  bony  ridge  or  crest.  In  the 
other,  the  area  of  fixation  is  more  diffused,  simulating  more  closely 
the  natural  process  of  repair.  An  anchylosing  operation  upon  a 
tuberculous  joint  assures  repair  by  removing  the  diseased  area  and 
destroying  the  articulation.  The  operation  on  the  spine  cannot 
remove  the  disease  but  it  favors  repair  by  fixation  of  the  diseased 
area. 

1  Verband :  Deutschen  Orth.  Gesellschaft,  1915. 


116  TUBERCULOUS   DISEASE  OF    THE  SPINE 

It  should  })e  stated  that  operative  treatment  on  a  larger  scale 
has  not  proved  as  successful  as  the  immediate  results  presented  by 
Hibbs  and  Albee  would  indicate.  The  operations  are  not  free  from 
danger.  Satisfactory  fixation  is  not  always  secured,  nor  is  the  prog- 
ress of  the  disease  always  arrested.  In  a  recent  report  on  the  treat- 
ment of  Pott's  disease  at  the  New  York  Orthopedic  Hospital,  it  is 
stated  that  of  48  cases  operated  on  by  the  Hibbs  method  the  de- 
formity subsequently  increased  in  10,  or  20  per  cent.  Since  these 
cases  were  under  supervision  it  may  be  assumed  that  results  are  far 
less  satisfactory  under  ordinary  conditions. 

In  most  instances,  and  in  practically  all  of  the  younger  type,  the 
spine  should  be  protected  for  from  six  months  to  a  year,  the  patient 
being  kept  under  observation  for  a  much  longer  time. 

One  may  conclude,  therefore,  that  operative  treatment,  although 
of  the  greatest  value  in  selected  cases,  particularly  in  the  adolescent 
or  adult  class,  is  not  to  be  undertaken  as  a  routine  measure  in  the 
treatment  of  Pott's  disease,  but  that  it  is  distinctly  supplementary 
to  conservative  treatment. 

It  is  more  often  indicated  in  the  thoracic  region  where  motion  is 
comparatively  limited  than  in  the  lumbar  segment  where  it  is  so 
important,  while  the  cervical  spine  is  hardly  amenable  to  operative 
treatment.  Operations  of  this  character  are  more  likely  to  be  suc- 
cessful in  the  curative  sense  in  the  adolescent  or  adult  class  than  in 
early  childhood.  Furthermore,  since  cure  is  attained  at  the  expense 
of  movement  the  functional  results  of  conservative  treatment  in 
favorable  cases  are  better  in  this  respect  than  when  four  to  eight 
vertebrae  are  fused. 

The  Duration  of  the  Treatment  of  Pott's  Disease. — The  duration 
of  the  treatment  must  depend  upon  the  extent  and  severity  of 
the  disease.  It  may  be  divided  into  two  periods :  one  during  which 
the  disease  is  active,  when  fixation  is  indicated,  and  a  stage  of  re- 
covery, during  which  supervision  is  required.  During  the  first 
stage  the  destructive  process  may  increase  the  direct  deformity; 
diu-ing  the  later  period  of  weakness  the  distortion  may  increase, 
simply  because  of  the  general  inclination  toward  deformity  and 
because  of  the  atrophy  of  the  supporting  muscles.  A  certain  in- 
crease of  deformity  even  during  treatment  is  common  as  78  of  125 
(62  per  cent.)  cured  cases  reported  from  the  New  York  Orthopedic 
Hospital  (loc.  cit.). 

Tuberculosis  of  the  spine  is  slow  in  its  progress,  and  actual  ossifi- 
cation that  assures  repair  does  not  begin  according  to  Calve,^ 
until  about  three  years  after  the  onset  of  the  disease,  and  recovery 
is  often  insecure.  The  course  of  the  disease  is  shortest  in  the  cervi- 
cal region,  but  even  here  two  years  of  brace  treatment  will  prob- 
ably be  required,  and  in  the  lower  region  double  this  time  even  in 

1  Jour.  Am.  Orthop.  Assn.,  January,  1914. 


DURATION  OF   TREATMENT  117 

the  milder  type  of  cases.  The  average  duration  of  treatment  in 
the  cases  reported  from  the  New  York  Orthopedic  Hospital  (loc. 
cit.)  being  seven  and  one-half  years.  Active  treatment  should  be 
continued  as  long  as  there  is  evidence  of  disease.  The  absence 
of  actual  pain  and  discomfort  is  of  little  value  in  determining  the 
absolute  cure  if  braces  have  been  employed.  The  absence 
of  muscular  spasm  is  more  significant,  since  it  usually  presists  as 
long  as  the  disease  is  active.  The  presence  of  pain  on  passive 
motion  or  muscular  contraction  or  abscess  would,  of  course,  indi- 
cate the  necessity  of  further  treatment. 

Direct  palpation  is  of  some  value  in  determining  the  condi- 
tion of  the  affected  part.  During  the  progressive  stage,  careful, 
deep  pressure  over  the  spinous  processes  may  show  greater  mobility 
of  those  involved  in  the  disease.  During  the  stage  of  repair  and 
consolidation  the  mobility  is  replaced  by  rigidity.  The  appearance 
of  the  kyphosis  has  some  significance.  Jn  the  early  stage  of  the 
disease  its  area  is  not  clearly  defined,  but  when  consolidation  has 
taken  place  its  extent  is  shown  by  the  rigid  vertebrae,  which  stand 
out  separated  from  the  remainder  of  the  spine  by  a  well-marked 
sulcus,  which  is  much  deeper  below  than  above  the  kyphosis. 

Even  when  the  disease  appears  to  be  cured,  removal  of  sup- 
port should  be  tentative;  the  jacket  should  be  replaced  by  the 
corset,  or  the  brace  by  a  lighter  appliance;  then  support  may 
be  removed  at  night,  later  for  part  of  the  day,  and  at  last,  after 
many  months,  it  may  be  discarded.  Then  may  follow  massage 
of  the  atrophied  muscles  of  the  trunk  and  gentle  exercise. 

Such  careful  supervision  must  be  continued  for  a  much  longer 
time  if  the  best  ultimate  result  is  to  be  attained,  for,  as  has  been 
mentioned,  one  should  guard  against  the  secondary  distortions, 
which  may  be  due  simply  to  weakness  and  to  the  unfavorable 
mechanical  conditions  induced  by  the  primary  deformity.  If 
curvatures  of  the  spine  are  so  common  among  normal  individuals 
how  much  more  likely  is  deformity  to  increase  when  the  trunk  has 
been  weakened  by  disease  and  by  long  disuse  of  the  muscles. 

This  secondary  increase  of  deformity  is  not  so  much  to  be 
feared  after  the  cure  of  the  disease  in  the  lumbar  region,  be- 
cause of  the  favorable  attitude  of  erectness,  nor  is  it  likely  to 
be  marked  after  cure  in  the  cervical  region  of  the  spine;  but  in 
disease  of  the  upper  and  middle  dorsal  region  support  must  be 
continued  long  after  recovery,  and  supervision  must  be  exercised 
until  after  the  period  of  adolescence,  if  increase  of  the  deformity 
is  to  be  prevented. 

Recurrence  of  Disease  and  Later  Effects  of  Deformity. — The 
disease  may  recur  after  an  interval  of  many  years  of  apparent 
cure,  and  such  recurrences  are  often  accompanied  by  the  forma- 
tion of  an  abscess  or  by  paralysis. 

If  recovery  from  Pott's  disease  has  been  complete,  and  if  de- 


118  TUBERCULOUS  DISEASE  OF   THE  SPINE 

formity  has  been  prevented,  the  condition  of  the  patient  is  to 
all  intents  normal;  but  if  the  course  of  the  disease  has  been  pro- 
longed, and  if  the  deformity  is  great,  his  condition  is  abnormal 
He  is  unfitted  for  ordinary  occupations,  and  comparative  com- 
fort is  assured  only  by  constant  care.  Such  individuals  are  likely 
to  suffer  from  neuralgic  pain  about  the  weakened  spine  on  over- 
exertion or  whenever  the  general  condition  is  depressed  from  any 
cause.  In  such  cases  the  use  of  some  form  of  light  corset  adds  to 
the  comfort  of  the  patient. 

In  certain  instances  pain  localized  in  the  lateral  region  of  the 
trunk  may  be  caused  by  compression  of  an  intercostal  nerve,  or 
it  may  be  due  to  compression  of  the  tissues  between  the  last  rib 
and  the  pelvis.  In  several  cases  of  this  character  reported  by 
Goldthwait,  resection  of  a  portion  of  a  rib  at  the  seat  of  pain  relieved 
the  discomfort. 

Secondary  Deformities. — While  the  patient  is  under  treatment 
for  Pott's  disease  one  should  be  on  the  alert  to  prevent  other  de- 
formities that  may  follow  the  general  weakness  and  restriction 
of  normal  functions.  One  of  these  is  the  iveak  foot,  sometimes 
called  weak  ankle  or  flat-foot,  and  with  it  is  often  associated  a 
moderate  degree  of  knock-knee.  This  may  be  prevented  by  a 
shoe  of  proper  shape,  of  which  the  heel  and  sole  are  thickened 
slightly  on  tlie  inner  side.    ■ 


CHAPTER   li. 
NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE. 

SYPHILIS. 

Syphilis,  in  the  inherited  or  in  the  later  stages  of  the  acquired 
form,  may  affect  the  bones  of  the  spine  and  cause  local  deformity 
and  sjTiiptoms  that  cannot  be  dis- 
tinguished from  those  of  Pott's  dis- 
ease. 

Diagnosis. — As  compared  with 
tuberculosis  it  is  a  rare  disease  of 
the  spine. ^  Its  manifestations  are 
likely  to  be  general  in  character, 
the  deformity  of  the  spine  being 
but  one  of  many  evidences  of 
disease. 

If  syphilis  were  limited  to  the 
spine  and  simulated  the  symptoms 
and  the  deformity  of  Pott's  disease 
it  would  require  the  same  local 
treatment.  Specific  remedies  are 
indicated  if  one  suspects  the  pres- 
ence of  syphilitic  taint,  even  if  the 
local  disease  appears  to  be  tuber- 
culous in  character. 


MALIGNANT  DISEASE  OF  THE 
SPINE. 


Fig.  80. — Vertical  anteroposterior 
section  of  the  lumbar  spine,  showing 
deposit  of  gumma  in  the  posterior  part 
of  the  third  and  fourth  vertebrae. 
(After  Fournier.) 


Malignant  disease  of  the  spine 
is  a  comparatively  rare  affection, 
particularly  so  in  childhood.  In 
early  life  sarcoma  is  more  common 

than  carcinoma,  and  it  may  affect  the  spine  primarily.  Carcinoma 
is  almost  always  secondary  to  a  primary  tumor  elsewhere,  the  spine 
becoming  involved  by  metastasis  or  by  contiguity.  Schlesinger- 
in  3720  cases  of  carcinoma  found  secondary  growths  in  the  spine  in 
54,  but  Risley^  states  that  the  percentage  of  vertebral  metastasis 
from  cancer  of  the  breast  is  nearly  25  per  cent. 

1  Jasinski:  Arch.  f.  Dermat.  u.  Syph.,  Bd.  xxiii,  S.  400. 

2  Buckley:  Jour.  Nerv.  and  Ment.  Dis.,  April,  1902. 

3  Boston  Med.  and  Surg.  Jour.,  April  22,  1915. 


120       N  ON -TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

Diagnosis. — Malignant  disease  differs  from  tuberculosis  of 
the  spine  in  that  its  symptoms  are  usually  more  severe;  the  pain 
is  usually  persistent,  and  it  is  not  relieved  by  support  or  recum- 
bency, as  is  that  of  Pott's  disease.  The  constitutional  symptoms 
are  more  marked  and  the  steady  progress  of  the  disease  toward 
a  fatal  termination  is  soon  apparent.  Locally,  the  angular  de- 
formity is  slight,  and  it  may  be  absent.  Not  infrequently  the 
tumor  may  be  palpated  through  the  abdominal  wall. 

Paralysis  is  a  frequent  and  often  an  early  symptom,  usually 
aft'ecting  sensation  as  well  as  motion. 

As  has  been  stated,  carcinoma  is  almost  always  secondary  to 
disease  elsewhere.  In  20  per  cent.,  of  150  fatal  cases  of  cancer^ 
the  spine  was  involved  and  in  about  half  the  cases  the  diagnosis 
had  been  mtade  before  autopsy.  Thus,  if  after  the  operation  for 
the  removal  of  carcinoma  s^^nptoms  of  disease  of  the  spine  appear, 
one  should  suspect  this  complication. 

^Malignant  disease  of  the  spine  is  a  fatal  affection,  and  the  treat- 
ment can  be  but  palliative. 

ACUTE  OSTEOMYELITIS  OF  THE  SPINE. 

Infectious  osteomyelitis  of  the  spine  is  comparatively  uncommon, 
about  100  cases  having  been  recorded.-  The  bodies  of  the  verte- 
brae are  usually  involved,  e>  ceptionally  the  arches  or  other  parts. 

Symptoms. — The  symptoms  are  similar  to  those  of  acute  infec- 
tious processes  elsewhere,  and  are  characterized  by  sudden  onset, 
with  pain,  fever,  and  constitutional  depression.  There  are  local 
pain  and  sensitiveness  about  the  spine  and  in  many  instances  dis- 
tention of  the  veins  in  the  neighborhood  caused  by  interference 
with  the  circulation  by  septic  thrombosis.  Abscess  quickly  forms, 
and  paralysis  from  the  rapid  extension  of  the  disease  is  a  common 
complication.  The  symptoms  due  to  pyogenic  infection  and  to 
deep-seated  abscess  are  often  pyemic  in  character  and  necrosis 
of  the  aff'ected  vertebral  bodies  may  result  in  the  formation  of  large 
sequestra. 

In  61  cases  collected  from  literature,^  the  situation  of  the  disease 
was  as  follows: 

Cervical  region 12 

Thoracic  region 15 

Lumbar  region 24 

Sacral  region 10 

The  cause  of  the  infection  in  15  of  the  20  cases  examined 
was  the  Staphylococcus  aureus.     In  most  cases  the  original  focus 

^  Berrenberg-Gassler:  Ztschr.  f.  Chir.  u.  Median.  Orthop.,  January,  1913. 
^  Kirmisson:  Presse  Med.,  1909,  n.  38. 
3  Hunt:  Med.  Rec.,  April  23,  1904. 


INJURY  OF   THE  SPINE  121 

of  infection  was  a  furuncle,  inflammation  about  a  nail,  or  small 
abscess.^ 

In  40  of  56  cases  reported^  the  patient  died  of  general  infec- 
tion, pleuropneumonia,  or  meningitis  before  the  diagnosis  had 
been  made  and  before  abscess  had  appeared.  The  mortality  was 
about  56  per  cent. 

Recovered.  Died. 
Suboccipital  region        ..........        1  4 

Cervical 2  2 

Dorsal 7  3 

Lumbar 13  15 

Sacral 0  6 

23  30 

4. 

A  more  localized  and  more  chronic,  and  of  course  far  less  dan- 
gerous, form  of  osteomyelitis  may  occur,  and  abscess  may  be  the 
first  sign  of  the  disease.  In  all  cases  of  this  character,  whether 
acute  or  chronic,  other  bones  or  joints  or  other  tissues  are  often 
involved,  and  in  many  instances  an  infected  wound  or  discharging 
ear,  for  example,  may  indicate  the  source  of  infection. 

Treatment. — The  treatment  consists  in  the  immediate  evacuation 
and  drainage  of  the  abscess,  the  removal  of  the  necrosed  bone  if 
possible,  and  in  supporting  the  spine  during  the  subsequent  stage 
of  weakness. 

ACTINOMYCOSIS  OF  THE  SPINE. 

Actinomycosis  of  this  region  is  extremely  uncommon,  the  spme 
having  been  involved  secondarily  in  about  2  per  cent,  of  the  re- 
ported cases.^  The  diagnosis  may  be  made  by  the  microscopic 
examination  of  the  discharge  from  the  sinuses  that  almost  always 
form  when  bone  is  affected. 

INJURY  OF  THE  SPINE. 

Severe  strains  or  fractures  may  simulate  disease  very  closely, 
and  in  some  instances,  particularly  of  injury  of  the  cervical  region, 
the  diagnosis  unless  confirmed  by  the  x-ray  picture  is  practically 
impossible  until  after  treatment  by  support  and  fixation  has  been 
applied,  when,  as  a  rule,  if  disease  is  absent,  the  symptoms,  even 
though  of  long  standing,  quickly  subside.^ 

Fracture  of  the  spine  in  the  middle  region  may  cause  angular 
deformity,  and  in  untreated  cases  symptoms  of  pain  and  weakness, 
similar  to  those  of  Pott's  disease,  may  persist  indefinitely. 

1  Volkmann:  Deutsch.  Ztschr.  f.  Chir.,  1915,  Bd.  cxxxii,  s.  145. 

2  Grisel:  Revue  d'orthopedie,  September,  1903. 

3  Erving:  Johns  Hopkins  Hosp.  Bull.,  November,  1902. 

^  Mixter  and  Osgood:  Jour.  Am.  Orthop.  Assn.,  February,  1910. 


122       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

Crushing  of  one  or  more  of  the  vertebral  bodies  without  dis- 
placement and  without  severe  immediate  symptoms,  other  than 
the  slight  deformity,  may  be  the  result  of  injury,  especially  falls 
from  a  height.  These  cases  are  not  infrequent,  the  most  common 
site  being  the  dorsolumbar  junction,  and  as  the  severity  of  the  injury 
is  not  often  recognized,  the  local  deformity,  which  may  not  attract 
attention  until  several  weeks  after  the  accident,  combined  with 
stiffness  and  weakness,  may  be  mistaken  for  Pott's  disease. 

Rupture  of  spinal  ligaments  may  be  caused  by  forcible  flexion 
of  the  spine.  The  resulting  deformity  and  weakness  resemble 
the  symptoms  caused  by  a  crush  of  one  of  the  vertebral  bodies.^ 
Fracture  of  a  transverse  or  spinous  process  may  cause  local  sensi- 
tiveness and  pain  on  movement. 

Traumatic  Spondylitis. — KummelP  has  described  a  form  of 
rarefying  ostitis  of  the  spine  apparently'  caused  by  injury.  It 
is  characterized  by  sjniptoms  of  pain  and  weakness  referred  to 
the  back,  and  by  a  pronounced  rounded  kyphosis  of  the  dorsal 
region.  ]\Iotor  disturbances  of  the  lower  extremities  are  frequent. 
This  is  easily  explained  by  the  fact  that  in  cases  of  this  character 
fracture,  disorganization  of  the  disks,  rupture  of  ligaments,  hemor- 
rhage beneath  the  longitudinal  ligament,  into  the  muscles  or  into 
the  spinal  canal,  have  been  demonstrated  at  autopsy.  Indirect 
injury,  shock  to  the  nervous  apparatus  and  the  like  may  cause 
complicating  symptoms  in  addition.^ 

Ivummell's  cases  differ  onl}^  in  degree  from  those  of  injiu-y  that 
have  been  described.  In  fact,  in  the  neglected  cases  of  injury  of 
the  spine  the  pain  and  weakness  may  persist  indefinitely,  and  the 
deformity  may  increase.  In  certain  instances  there  may  be  a  sec- 
ondary infection,  tuberculous  or  otherwise,  at  the  seat  of  injury, 
and  in  others  the  injury  may  be  the  exciting  cause  of  spondylitis 
deformans,  but  such  results  are  unusual. 

Treatment. — In  all  such  cases,  and  whenever  weakness  of  the 
spine  persists,  and  if  motion  causes  pain,  a  support  should  be 
applied  as  in  the  treatment  of  Pott's  disease.  If  possible,  deform- 
ity if  of  recent  origin  should  be  corrected  in  suitable  cases  by  gentle 
manipulation  under  anesthesia.  In  others,  by  recumbency  and 
hyperextension  or  by  the  Calot  jacket.  ]\Iassage  and  graduated 
exercises  are  of  value  during  the  period  of  recovery.  Clinical 
evidence  indicates  that  repair  is  slow:  support  therefore  should 
be  continued  for  at  least  six  months  and  for  a  much  longer  time  if 
the  injury  is  of  the  middle  dorsal  region  where  the  tendency  to 
postm*al  deformity  is  so  marked. 

1  Painter  and  Osgood:  Boston  Med.  and  Surg.  Jour.,  Januarj-  2,  1902. 

2  Deutsch.  med.  Wchnschr.,  1895,  No.  11. 

3  Renter:  Arch.  f.  Orthop.  u.  Unfallchirurgie,  1904,  B.  ii,  H.  2. 


INFECTIOUS  DISEASES  OF  THE  SPINE  123 

INFECTIOUS  DISEASES   OF  THE  COVERINGS   OR  ARTICU- 
LATIONS OF  THE  SPINE. 

The  "Typhoid  Spine." — During  the  course  of  or  during  con- 
valescence from  typhoid  fever,  and  occasionally  after  apparent 
recovery  from  the  disease,  symptoms  of  pain,  weakness,  and  stiff- 
ness of  the  back  may  appear,  sometimes  induced  by  sudden  strain 
or  other  injury,  and  usually  localized  in  the  dorsolumbar  region. 
The  cause  is  apparently  a  secondary  infection  of  the  fibrous  coverings 
and  articulations  of  the  spine,  similar  to  the  more  common  but 
more  severe  forms  of  periostitis  of  the  tibia  or  other  bones,  from  the 
same  cause.  There  is  usually  pain  on  motion,  reflected  along  the 
nerves.  In  some  instances  this  is  extreme,  and  there  may  be  ac- 
companying muscular  "cramps"  in  the  limbs,  local  muscular  spasm, 
and  pain  on  pressure  over  the  affected  vertebrae.  The  temperature 
is  often  above  normal,  with  irregular  and  sometimes  extreme 
fluctuations  in  severe  cases. 

In  many  instances  a  neurotic  element  is  present,  induced,  doubt- 
less, by  the  preceding  disease.  The  complication  is  most  common 
in  young  adults,  males  in  an  estimated  proportion  of  1  to  1800 
cases  of  typhoid  fever.^ 

In  6  of  68  cases  tabulated  by  Wurtz^  the  patients  were 
children,  and  several  of  this  class  have  come  under  my  observation. 

Diagnosis. — The  diagnosis  is  usually  made  clear  by  the  history 
of  the  disease  of  which  it  is  a  complication. 

Treatment. — The  treatment  should  be  symptomatic.  During 
the  active  stage,  if  pain  is  severe,  the  patient  should  remain  in 
the  recumbent  position,  if  necessary  on  the  stretcher  frame.  Lo- 
cally, the  application  of  the  Paquelin  cautery  is  of  service.  As 
soon  as  is  practicable  a  back  brace  or  other  support  should  be  applied 
which  should  be  worn  until  the  symptoms  have  subsided.  Complete 
recovery  is  the  rule,  the  duration  of  the  symptoms  averaging  about 
six  months.  Restriction  of  motion  may  persist  accompanied  by 
slight  deformity  in  the  more  severe  type  of  cases. 

This  description  applies  particularly  to  cases  of  a  mild  type  de- 
scribed by  Gibney^  as  typhoid  spine.  Disease  of  the  spine  complicat- 
ing typhoid  fever  was  first  described  by  Maisonneuve  in  1835. 
Terrillon^  classifies  the  lesions  of  typhoid  infection  of  the  spine  as: 

1.  Simple  periostitis. 

2.  Periostitis  with  subperiosteal  abscess. 

3.  Periostitis  with  ostitis.^ 

1  Gall:  Miinchen.  med.  Wchnschr.,  April  13,  1915. 

2  Boston  Med.  and  Surg.  Jour.,  June  26,  1902.  Rogers:  Boston  Med.  and  Surg., 
Jour.,    cxviii.    No.    10. 

s  Gibney:  Tr.  Am.  Orthop.  Assn.,  ii.  <  Le  Prog.  Med.,  April  12,  1884. 

*  In  533  typhoid  bone  lesions  the  skull  was  involved  in  22  cases,  the  spine  in  110, 
the  thorax  in  142,  the  upper  extremities  in  57,  lower  extremities  in  83,  and  multiple 
bones  were  involved  in  19.     Murphy,  Surg.  Gyn.  and  Obst.,  August,  1916. 


124       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

In  36  per  cent,  of  53  cases  investigated  by  Silver^  local  deformity 
indicated  a  destructive  process. 

Other  Forms  of  Infectious  Disease. — Symptoms  resembling 
those  described  may  follow  other  forms  of  contagious  disease, 
notably  scarlatina,  but,  as  a  rule,  they  are  much  less  persistent 
and  less  severe. 

"Gonorrheal  rheumatism"  of  the  spine  is  uncommon.  Its 
symptoms  and  pathology  resemble  those  of  the  tj^^hoid  spine. 
Anchylosis  is,  however,  more  common  as  a  result  than  after  other 
forms  of  infection;  in  fact,  gonorrhea  is  apparently  one  of  the  more 
common  causes  of  spondylitis  deformans. 

Treatment. — The  treatment,  aside  from  that  of  the  exciting  cause, 
is  symptomatic.     Local  support  is  indicated  in  many  instances. 

Arthritis  of  the  Suboccipital  Region. — The  articulations  of  the 
occipito-axoid  region  are  sometimes  affected  by  what  appears  to 
be  a  form  of  acute  or  subacute  infectious  or  toxic  arthritis  similar 
in  characteristics  to  acute  rheumatism.  It  may  follow  tonsillitis, 
diphtheria,  or  other  contagious  disease.  It  may  be  distinguished 
from  tuberculous  disease  by  its  acute  onset  and  from  acute  torti- 
collis by  the  fact  that  all  motions  are  restricted. 

Treatment. — ^The  treatment  consists  in  support  preferably  of 
the  jury-mast  type  during  the  acute  stage,  followed  by  massage, 
manipulation,  and  exercise  to  overcome  the  subsequent  stiffness. 

Spondylitis  Deformans. — Synonyms. — Osteo-arthritis  of  the  spine; 
spondylose  rhizomelique;  stiffness  of  the  vertebral  column. 

Spondylitis  deformans  is  a  chronic  progressive  disease  of  the 
spine  terminating  in  anchylosis  and  deformity. 

Pathology. — The  disease  is  apparently  a  chronic  inflammation 
affecting  primarily  the  ligaments  and  the  periosteal  coverings 
of  the  spine,  a  form  of  ossifying  periostitis  which  binds  the  ver- 
tebrae firmly  to  one  another  (Fig.  81).  It  may  begin  on  the  lateral 
or  on  the  anterior  aspect  of  the  spine;  it  may  be  limited  to  a  par- 
ticular region,  but  in  most  instances  it  eventually  involves  the 
entire  spine  and  often  the  articulations  of  the  ribs  as  well.  The 
intervertebral  disks  atrophy  and  the  spine  becomes  anchylosed. 
In  some  instances  the  margins  of  the  cartilages  proliferate  and  be- 
come ossified  in  a  manner  characteristic  of  osteo-arthritis  of  the 
the  joints. 

Under  the  general  term  of  spondylitis  deformans  are  included, 
clinically,  several  varieties  of  disease,  for  example: 

1.  The  affection  of  the  spine  may  be  simply  one  of  the  mani- 
festations of  chronic  polyarthritis — "rheumatoid  arthritis"  of  the 
spine. 

2.  The  spine  may  be  involved  together  with  one  or  more  of  the 
adjacent  joints  which  present  the  characteristic  sjTnptoms  of  the 

1  Silver:   Am.  Jour.  Orthop.  Surg.,  v,  194. 


SPONDYLITIS  DEFORMANS 


125 


so-called  hypertrophic  form  of  arthritis  deformans — osteo-arthritis  of 
the  spine.  This  form  has  been  designated  by  Marie  spondylose 
rhizomelique  (from  spondylos,  spine;  rhizo,  root;  and  melos,  extrem- 
ity), signifying  a  disease  of  the  spine  together  with  the  adjoining 
"root"  joints.i 

3.  The  disease  may  be  limited  to  the  spine,  and  in  such  cases 
it  appears  to  be  clinically  distinct  from  characteristic  general 
arthritis  or  atrophic  or  hypertrophic  arthritis.  It  may  follow 
acute  polyarthritis,  it  may  be  induced  apparently  by  gonorrhea 


Fig.  81. — Spondylitis  deformans  (osteo-arthritis).      (Goldthwait.) 

or  by  other  forms  of  infection,  or  by  injury — "traumatic  spon- 
dylitis." It  may  begin  acutely,  or  it  may  be  chronic  in  character 
and  progress  slowly.^  It  may  be  limited  to  a  particular  section  of 
the  spine,  although,  as  a  rule,  the  other  regions  are  progressively 
involved. 

This  form  of  limited  spondylitis  is  more  often  seen  in  young 
adults  from  twenty  to  forty  years  of  age,  and  in  at  least  80  per 


1  Marie:  Rev.  de  med.,  1898,  xviii. 

2  Bechterew:  Neurol.  Centralbl.,  ii,  426;  Senator:  Berl.  klin.  Wchnschr.,  November 
20,  1897. 


126       NOX-TVBERCULOUS  AFFECTIONS  OF   THE  SPIXE 

cent,  of  the  cases  the  patients  are  males.     Fmally,  in  a  mild  form,  it 
is  very  common  among  middle-aged  laborers. 

Symptoms. — In  the  ordinary  cases  there  is  usually  an  acute  onset 
from  which  the  patient  dates  the  beginning  of  his  trouble,  often  so- 
called  lumbago,  followed  by  a  gradually  increasing  stiffness  of  the 
spine  and  accompanying  deformity.  The  patient  complains  of 
stiffness,  weakness,  pain  in  the  loins,  and  of  pain  radiating  forward 
along  the  ribs;  sometimes  of  weakness  in  the  limbs,  headache, 
nervousness,   and  the  like — s^^nptoms  that  may  be  explained  in 


Fig.  82. — Spondylitis  deformans,  showing  the  characteristic  curvature  of  the 
spine.  Age  of  the  patient,  twenty-three  years.  Duration  of  the  disease  three  years; 
cause  unknown.     No  other  joints  involved. 

part  by  the  inflammatory  process  and  by  implication  of  the  nerve 
roots,  and  in  part  by  an  accompanying  neurasthenia.  The  direct 
s^Tiiptoms  are  increased  by  jars,  which  are  exaggerated  by  the  in- 
elasticity of  the  spine.  The  disease  is  usually  progressive,  and  ter- 
minates finally  in  complete  rigidity  of  the  spine,  which  is  bent  into 
a  long  k^-phosis,  most  marked  in  the  upper  dorsal  region,  the  lumbar 
lordosis  being  obliterated  in  many  instances  (Fig.  S3). 

The  straightening  of  the  spine  in  the  middle  and  lower  region 
exaggerates  the  forward  thrust  of  the  neck,  and  in  some  instances 


SPONDYLITIS  DEFORMANS 


127 


the  patients  complain  of  a  disturbance  of  equilibrium,  especially 
of  a  tendency  to  fall  forward. 

When  the  disease  is  limited  to  the  spine  or  to  the  spine  and  one 
or  more  of  the  larger  joints,  the  occipito-axoid  articulations  are  not 
usually  involved;  but  in  the  general  form  of  the  disease — "rheu- 
matoid arthritis" — they  are  often  primarily  affected. 


Fig.  83. — Spondylitis  defor- 
mans, illustrating  the  characteris- 
tic deformity.  Age  of  the  patient, 
thirty  years.  Spine  rigid,  with  the 
exception  of  the  occipito-axoid 
articulation.  Duration  two  years; 
cause  unknown.  No  joints  in- 
volved. 


Fig.  84. — Spondylitis   deformans  in  a   child. 


The  types  of  the  disease  may  be  illustrated  by  a  brief  description 
of  cases  recently  under  observation. 

Type  I.  ".  Rheumatoid  Arthritis"  of  the  Sjnne.— In  this  case,  that 
of  a  boy  ten  years  of  age,  there  was  characteristic  general  chronic 
(atrophic)  arthritis  that  involved  nearly  every  joint  of  the  body. 


128       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

The  entire  spine,  even  including  the  occipito-axoid  joints,  wasTigid 
and  the  head  was  fixed  in  an  attitude  of  extreme  torticoUis. 

Type  II.  "  Osteo-arthritis  of  the  Spine"  ("spondylose  rhizome- 
Hque"). — A  man  aged  forty-six  years,  after  repeated  attacks  of 
so-called  rheumatism  involving  the  larger  joints,  gradually  became 
disabled  because  of  pain  and  stiffness  of  the  back  and  because  of 
his  inability  to  stand  erect.  In  this  case  there  was  complete  anchy- 
losis of  the  spine,  except  of  the  small  joints  of  the  cervical  region, 
and  in  addition  the  right  thigh  was  flexed  upon  the  body  at  such  an 


Fig.  85. — Anchylosing  disease  of  the  spine  following  gonorrhea  causing  lateral 
distortion  of  the  pelvis. 


angle  that  the  patient  could  walk  only  with  an  exaggerated  stoop. 
The  joints  of  the  feet  were  slightly  involved  also.  No  cause  other 
than  exposure  to  cold  and  dampness  could  be  assigned.  The  sjnip- 
toms  were  of  two  years'  duration,  periods  of  comfort  alternating 
with  disabling  attacks  of  "rheumatism." 

Type  III.  Spondylitis  Deformans. — The  spine  of  this  patient, 
a  man  aged  forty-six  years,  was  absolutely  anchylosed  in  the 
characteristic  position.  The  occipito-axoid  joints  were  not  involved. 
Fourteen  years  before  he  had  suft'ered  from  a  severe  and  prolonged 
attack  of  "inflammatory  rheumatism,"  affecting  nearly  every  joint. 


SPONDYLITIS  DEFORMANS  129 

but  not  the  spine,  and  during  a  succeeding  period  of  nine  years 
he  had  been  disabled  several  times  from  the  same  cause.  Each 
illness  was  coincident  with  gonorrhea.  Five  years  before  examina- 
tion the  "rheumatism"  had  involved  the  spine,  and  since  then  he 
had  suffered  from  persistent  "lumbago."  Gradually  the  stiffness 
of  the  spine  had  increased,  but  during  this  time  he  had  been  free 
from  gonorrhea,  and  from  rheumatism  as  well.  The  joints  were 
normal  in  appearance  and  function.  This  patient  suffers  prin- 
cipally from  nervousness  and  irritability;  he  is  easily  startled;  he 
feels  as  if  his  forehead  was  clasped  by  a  tight  band.  His  direct 
symptoms  are  pain  in  the  loins  and  pain  radiating  under  the  shoul- 
der-blades, increased  by  walking  or  by  jars.  His  equilibrium  is 
disturbed  by  the  forward  projection  of  the  head  and  by  the  ob- 
literation of  the  normal  lordosis,  so  that  he  feels  himself  constantly 
inclined  to  fall  forward,  whether  he  is  sitting  or  standing. 

Type  IV.  In  another  case  very  similar  to  this,  in  a  man  aged 
thirty  years,  the  spine  had  become  rigid  in  a  few  months.  The 
patient  ascribed  the  disease  to  sleeping  out  of  doors.  There  was 
in  this  case  coincident  tuberculous  disease  of  the  lungs.  And  in 
this  instance  the  cause  of  the  deformity  may  have  been  superficial 
tuberculous  disease  or  so-called  tuberculous  rheumatism. 

Type  V.  A  man  aged  sixty-two  years,  presenting  the  char- 
acteristic deformity  and  symptoms  of  the  subacute  type,  gave 
the  following  account  of  the  affection:  Fifteen  years  before,  he 
had  suffered  from  "chronic  lumbago."  The  pain  and  stiffness, 
at  first  limited  to  the  lower  region  of  the  spine,  had,  with  inter- 
vening periods  of  remission,  gradually  ascended,  and  at  the  time 
of  examination  the  cervical  region  was  the  seat  of  the  more  active 
process.  He  had  been  treated  by  internal  remedies,  by  baths, 
and  by  change  of  climate,  without  avail.  He  knew  he  had  the 
"old  man's  stoop,"  but  he  was  surprised  to  learn  that  the  cause 
of  his  symptoms  was  a  disease  of  the  spine.  The  spine  was  rigid, 
although  not  anchylosed,  as  indicated  by  the  discomfort  on  chang- 
ing from  one  position  to  another.  The  occipito-axoid  articulations 
and  the  other  joints  were  free  from  disease. 

This  subacute  form  of  the  affection  is  very  common,  and,  as  in 
this  instance,  the  patients  are  usually  treated  for  rheumatism, 
muscular  or  otherwise,  for  many  years  before  the  true  diagnosis 
is  made. 

Treatment. — The  general  treatment,  dietetic,  climatic  and  the 
like,  should  include  if  possible  the  removal  of  the  exciting  causes, 
persistent  gonorrhea  in  the  younger  subjects  being  apparently 
the  most  common  of  these.  The  local  treatment  is  symptomatic. 
Massage  of  the  muscles,  hot  baths,  and  the  like  may  add  to  the 
comfort  of  the  patient,  but  violent  exercise  or  passive  movements 
of  the  spine  are  harmful.  Support  is  always  indicated  during  the 
progressive  stage  of  the  affection,  and  it  is  the  only  efficient  remedy. 
9 


130       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

The  support  may  be  in  the  form  of  a  hght  brace  or  jacket.  It  is 
particularly  efficacious  when  the  disease  is  limited  to  the  lower  and 
middle  regions  of  the  spine.  In  such  cases  under  efficient  pro- 
tection the  muscular  spasm  subsides  and  motion  returns  in  some 
degree.  Even  in  progressive  cases  one  may  hope  to  preserve  the 
lumbar  lordosis,  and  thus  to  lessen  the  general  effect  of  the  de- 
formity when  the  spine  becomes  rigid.  In  certain  instances  in 
in  which  anchylosis  is  not  established,  particularly  in  young  subjects, 


Fig.  86. — Extreme  posterior  curvature  of  the  spine  in  adolescence,  showing  retraction 
of  the  abdomen.    This  deformity  may  be  mistaken  for  spondylitis  deformans. 


force  may  be  employed  with  caution,  to  improve  the  contour  of  the 
spine,  particularly  with  the  aim  of  reestablishing  the  lumbar 
lordosis,  and  thus  enabling  the  patient  to  stand  erect.  The  patient 
learns  by  experience  what  exercises  or  postures  increase  the  discom- 
fort, and  these  should  be  avoided  if  possible.  The  application  of  a 
cautery  is  often  of  service,  and  self-suspension  at  intervals  may 
relieve  the  dragging  sensation  in  the  muscles.  Rubber  heels  are 
useful  in  lessening  the  jar.     As  has  been  stated,  in  some  cases  the 


THE  RHACHITIC  SPINE  131 

disease  remains  localized,  but  ordinarily  it  extends  along  the  spine. 
When  a  part  of  the  spine  becomes  firmly  anchylosed  the  local 
discomfort  lessens  or  ceases,  and  is  transferred  to  the  part  where  the 
process  is  still  advancing. 

Kyphosis  of  Adolescents. — A  form  of  extreme  kyphosis  accom- 
panied by  stiffness  and  discomfort  is  sometimes  seen.  It  appears 
to  be  a  static  deformity  induced  by  overwork  in  rapidly  growing 
adolescents,  which  finally  becomes  fixed  by  accommodative  changes 
in  the  bones  and  neighboring  tissues.  It  can  hardly  be  classified 
with  spondylitis  deformans,  although  there  may  be  some  difficulty 
in  distinguishing  between  the  two  (Fig.  86).  In  favorable  cases 
partial  rectiiication  of  the  deformity  by  force  (the  Calot  operation) 
is  indicated.  Afterward  support,  forcible  movements,  and  cor- 
rective exercises  should  be  employed. 

THE  RHACHITIC  SPINE. 

The  rhachitic  spine  has  been  described  in  the  consideration  of 
the  differential  diagnosis  of  Pott's  disease.  It  usually  develops 
during  the  first  or  second  year  of  life,  in  children  who  sit  the  greater 
part  of  the  time;  it  is,  in  fact,  simply  an  exaggeration  of  the  con- 
tour that  is  normal  in  the  sitting  posture.  The  typical  rhachitic 
kyphosis  is  thus  a  rounded  projection  of  the  lower  region  of  the 
spine,  which  is  more  or  less  rigid  according  to  its  duration.  If  the 
deformity  is  extreme  there  may  be  a  compensatory  backward  incli- 
nation of  the  head,  which  may  be  accompanied  by  contraction  of 
the  posterior  group  of  muscles,  "cervical  opisthotonos." 

Treatment. — Aside  from  the  constitutional  treatment  of  the 
rhachitic  condition,  and  from  the  measures  that  should  be  employed 
to  improve  the  nutrition  of  the  muscles  in  general,  the  indications 
are  to  overcome  the  deformity  and  the  limitation  of  motion  of  the 
spine;  to  support  it,  if  necessary,  during  the  stage  of  weakness;  and 
to  prevent,  as  far  as  possible,  the  postures  that  favor  the  distortion. 

The  correction  of  the  deformity  may  be  accomplished  by  massage 
and  by  direct  manipulation  of  the  spine.  The  child  lying  face 
downward,  on  a  table;  one  hand  is  placed  on  the  projection,  and 
with  the  other  the  legs  are  raised  to  throw  the  spine  into  a  position 
of  overextension.  This  stretching  is  performed  slowly  and  care- 
fully over  and  over  again  at  morning  and  night,  and  the  manipu- 
lation is  followed  by  thorough  massage  of  the  muscles.  If  the  de- 
formity is  marked  and  if  the  general  rhachitic  process  is  still  active, 
the  recumbent  posture,  on  a  light  frame,  in  an  attitude  of  over- 
extension may  be  indicated  as  described  in  the  treatment  of  Pott's 
disease. 

For  older  subjects  some  form  of  light  back  brace  may  be  suffi- 
cient in  connection  with  the  massage,  and  systematic  correction 
of  the  deformity. 


132       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

The  Natural  Cure. — It  may  be  stated  that  the  rhachitic  spine  is 
to  a  certain  extent  corrected  when  the  erect  posture  is  assumed, 
by  the  inchnation  of  the  pelvis  and  accompanying  lordosis.  This 
natural  cure  is,  however,  often  rather  a  distribution  of  deformity 
than  a  cure,  for  the  upper  part  of  the  projection  may  remain  as  an 
exaggeration  of  the  normal  dorsal  kyphosis  balanced  by  an  exag- 
gerated lordosis,  ''the  rhachitic  attitude."  In  other  instances  the 
persistence  of  the  lumbar  kyphosis  may  induce  a  compensatory 
flattening  of  the  normal  dorsal  k\'phosis.  Thus,  rhachitis  may 
cause  the  so-called  _^a^-feac A-  as  well. 


Fig.  87. — Rhachitic  kj-phosis. 

It  may  be  mentioned  that  rotary  lateral  curvature  of  the  spine, 
one  of  the  common  deformities  induced  by  rhachitis,  is  far  more 
serious  than  the  anteroposterior  curvature,  with  which  it  is  occasion- 
ally combined.     Its  treatment  is  considered  in  Chapter  III. 

Osteitis  Deformans. — Osteitis  deformans  is  a  general  disease 
characterized  by  hypertrophy  and  softening  of  the  bones.  The 
deformity  of  the  spine  is  similar  to  that  of  spondylitis  deformans, 
but  the  rigidity  is  not  as  marked,  and  the  discomfort  is  far  less  than 
in  this  affection. 


SPONDYLOLISTHESIS 


133 


Tabetic  Deformity  of  the  Spine. — In  rare  instances  deformity 
of  the  spine,  either  posterior  or  lateral,  appears  as  a  compHcation 
of  locomotor  ataxia.     These  diseases  are  described  elsewhere. 


Fig.  88. — Spondylolisthesis. 


Fig.  89. — Small  pelvis  of  Prague  (median  section).     Illustrating  slight  forward  dis- 
placement of  the  body  of  the  fifth  lumbar  vertebra.     (Neugebauer.) 

Spondylolisthesis. — Spondylolisthesis  is  a  deformity  in  which  the 
body  of  one  of  the  lower  lumbar  vertebrae,  usually  the  fifth,  is  dis- 


134       NOX-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE 


placed  forward  and  downward  (Fig.  91).  The  relative  weakness  of 
the  ligamentous  support,  the  inclination  of  the  upper  surface  of 
the  sacrum  and  the  mobility  of  the  articulation  favor  displacement 
at  this  point.  In  certain  instances  the  spinous  process  may  remain 
in  its  normal  position,  while  the  laminae  become  elongated  or  sepa- 
rated from  the  body  (Fig.  89).     The  condition  was  first  described 

by  Killian  in  1854,  and  it  was  thor- 
"  Ij^^Bi]      oughly  investigated  by  Xeugebauer  in 

^^^H[  The   causes    are    congenital   malfor- 

KS^^      mation,    iniurv,  overstrain,  or    disease 
Wk^  /       of  the  lumbosacral  articulation.     Lane 
^H^^      states    that    slighter  degrees  of  the  de- 
^S^^m      formity    are     often     observed    among 
J^^K^      laborers. ..   The  trunk  is    displaced  for- 
ward and  downward  in  its  relation  to 
the  pelvis.     The  sacrum  rotates  back- 
ward and  the  inclination  of  the  pelvis 
is  lessened  or  lost,  the  space  between  the 
ribs  and  the    iliac   crests  being  corre- 
spondingly   diminished.     In    some    in- 
stances the  contour  of  the  back  is  flat, 
although  the  trunk  is  inclined   back- 
ward; in  others  there  is   a    sharp  for- 
ward inclination  above  the  projecting 
sacrum  (Fig.  90).     Forward  bending  of 
the  spine  is  much  restricted.    • 

The  typical  deformity  is  most  often 

seen  in  women;  and  it  first  attracted 

attention  because  of    its  influence   on 

parturition.     In  males  it  is  usually  the 

result    of    injury.      The    characteristic 

s^inptoms  are  weakness  and  discomfort 

in  the  lumbar   region  [and   pain  about 

the    distribution    of    the    lumbar    and 

sciatic  nerves.     In  advanced  cases  the 

gait  is  awkward  and  it  may  be  almost 

ataxic    in  character.     Several  cases  of 

transient   or   persistent  paralysis  have 

been  recorded,  caused  by  pressure  on 

the  cord.^ 

Treatment. — In  cases  of  the  ordinary  t;s^e  and  particularly  if 

the  deformity  is  the  result  of  injiu-y  a  strong  corset  or  back  brace 

of  the  Knight  or  Taylor  t^'pe  is  indicated.     If  the  deformity  is 

progressive  the  insertion  of  a  bone  graft  after  the  Albee  method, 


Fig.  90.  —  Spondylolisthesis 
ia  an  adolescent,  induced  ap- 
parently by  overwork.  Symp- 
toms: inability  to  bend  for- 
ward and  pain  on  fatigue,  radi- 
ating down  back  of  the  thighs. 


1  Rverson:  Jour.  Am.  Med.  Assn.,  Januarj-  2,  1915. 


PAIN  IN   THE  BACK 


135 


into  the  lumbar  and  sacral  spinous  processes,  is  the  most  effective 
remedy.  For  the  mild  congenital  cases  seen  in  young  subjects 
exercise  to  prevent  the  limitation  of  flexion,  and  the  avoidance  of 
postures  that  favor  deformity  are  usually  efficacious  in  checking 
the  progress  of  the  distortion  and  in  relieving  the  weakness  and 
awkwardness  that  it  induces. 


Fig.  91.- 


-Spondylolistiiesis.     Showing  the  outline  of  the  body  of  the  fifth  lumbar 
vei'tebra  projecting  into  the  pelvis. 


PAIN  IN  THE  BACK. 

Discomfort  in  the  lumbar  region  of  the  character  of  fatigue, 
and  even  actual  pain  are  sometimes  caused  by  disease  or  by  displace- 
ments of  the  pelvic  or  abdominal  organs.  Pain  in  this  region  is 
also  a  common  symptom  among  overworked  women.  It  is  also 
induced  by  weak  feet  or  by  any  disturbance  of  the  balance  of  the 
spine.  It  is  often  present  if  the  lumbar  lordosis  is  exaggerated  as 
a  compensatory  deformity  for  dorsal  Pott's  disease,  or  because  of 
flexion  of  the  thigh  after  hip  disease.  Lovett^  analyzed  83  cases 
of  "backache,"  54  in  females,  29  in  males.  In  41  the  cause  seemed 
to  be  an  improper  inclination  of  the  spine,  usuaUy  a  forward  [droop 
of  the  trunk.     In  15  the  feet  were  weak,  35  cases  were  the  result  of 


1  Jour.  Am.  Med.  Assn.,  May  23,  1914. 


136       NOX-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

injury  or  arthritis.  Six  were  caused  by  pelvic  disorders;  5  by  promi- 
nent abdomen  and  1  was  an  acute  lumbago.     (See  Neurotic  Spine.) 

As  a  result  of  strain  or  other  injury  symptoms  of  pain  and  weak- 
ness in  the  lumbar  region,  increased  by  sudden  motions  or  over- 
exertion, may  be  persistent  and  disabling.  Such  cases  are  often 
classed  as  chronic  lumbago,  but  it  is  probable  that  there  is  in  many 
instances  a  distinct  injury  of  the  ligaments  or  deep  muscles  of  the 
spine,  fracture  of  a  transverse  process  or  strain  or  displacement, 
at  the  sacro-iliac  articulation,  aggravated,  it  may  be  in  certain  cases, 
by  rheumatism  or  other  general  affection  of  like  character. 

Ludloff^  has  called  attention  to  the  fact  that  persistent  pain  about 
the  sacrum  following  falls  or  other  injuries  may  be  explained  in  many 
instances  by  a  slight  degree  of  traumatic  spondylolisthesis.  Hunt^ 
has  noted  cases  characterized  by  intermittent  pain  and  cramps  in 
the  lumbar  muscles  induced  by  muscular  exertion  which  he  classifies 
as  ischemic  lumbago. 

Treatment. — The  treatment  must  be  primarily  directed  to  the 
condition  of  which  the  pain  is  a  symptom. 

If  motion  causes  pain  and  if  the  symptoms  are  persistent,  as 
in  the  Imnbago  type  of  cases,  whether  due  to  injury  or  to  inflam- 
mation of  the  fibrous  or  muscular  tissues,  support  is  indicated, 
in  mild  cases  a  stiffened  corset  will  serve  the  purpose,  in  others  a 
Knight  brace  or  plaster  corset  may  be  required.  During  the  more 
acute  stage  the  application  of  the  cautery  and  the  support  of  inter- 
secting strips  of  adhesive  plaster,  covering  a  wide  area,  even  en- 
circling the  pelvis,  will  often  relieve  the  pain.  Later,  massage, 
electricity,  and  the  like  are  of  service. 

In  milder  cases,  in  which  the  s\Tnptoms  may  be  dependent  on  a 
general  visceroptosis  an  abdominal  belt  will  often  afford  great  relief. 

DEFORMITY  SECONDARY  TO  SCIATICA. 

Synonym. — Sciatic  scoliosis. 

Chronic  sciatica  often  induces  a  change  in  the  attitude  and 
contour  of  the  spine  that  may  become  a  permanent  deformity  if 
its  cause  persists.  As  a  rule  the  patient  habitually  inclines  the 
body  away  from  the  painful  part  in  order  to  relieve  it  from  weight, 
bends  the  body  slightly  forward  and  abducts  the  limb  to  relax 
the  tension  on  the  sensitive  nerve  or  plexus  of  nerves.  Thus  the 
pelvis  on  the  affected  side  projects,  there  is  a  lateral  lumbar  con- 
vexity toward  the  opposite  side,  and  often  the  normal  lumbar 
lordosis  is  lessened  or  lost,  so  that  the  final  result  may  be  a  persistent 
lateral  curvature,  together  with  a  change  in  the  anteroposterior 
contour  of  the  spine.  If  the  deformity  persists  a  second  compen- 
satory curve  may  appear  (Fig.  92).     If  the  sciatica  is  a  s^^llptom  of 

1  Fortsch.  auf  d.  Gebiete  der  Roentgenstralilen,  Bd.  is,  Heft  3. 
-  Jour.  Am.  Med.  Assn.,  July  28,  1914. 


DEFORMITY  SECONDARY   TO  SCIATICA  137 

a  more  widespread  neuritis,  muscular  weakness  and  muscular 
spasm  may  cause  variations  in  the  typical  attitude,  the  muscles  of 
one  side  being  persistently  contracted. 


Fig.  92. — Typical  sciatic  scoliosis. 

It  must  be  borne  in  mind  that  disease  of  the  llumbar  spine, 
particularly  at  the  lumbosacral  articulation,  or  injury  or  disease 
at  the  sacro- iliac  junction,  may  induce  similar  distortion  of  the  spine 
accompanied  by  pain  in  the  limbs.     Also  that  disease  of  the  pelvic 


138       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

bones  or  of  the  adjacent  organs  or  parts,  may  set  up  sciatica;  thus 
the  cause  of  pain  should  be  carefully  sought  for. 

Aside  from  the  direct  treatment  of  sciatica,  support  for  the  spine, 
preferably  a  light  corset,  or  brace,  so  arranged  as  to  assure  the 
lumbar  lordosis  and  to  exert  firm  pressure  about  the  pelvis,  is  always 
indicated  if  movement  of  the  trunk  aggravates  the  pain.  If  the 
deformity  is  resistent  it  may  be  corrected  gradually,  by  repeated 
applications  of  a  plaster  jacket,  or  under  anesthesia,  in  which  cases 


Fig.  93  Fig.  94 

Figs.  93  and  9'4  illustrate  extreme  distortion  of  the  sciatic  type. 

the  deformity  should  be  overcorrected,  the  lumbar  lordosis  restored 
and  the  limb  and  trunk  fixed  by  a  long  plaster  spica  as  described 
under  Sacro-iliac  Strain.  Caudal  neuritis  may  cause  pain  in  the 
thighs  and  weakness  of  the  muscles  resembling  somewhat  sciatica, 
or  sacro-iliac  strain. 

Neuritis  in  other  regions  of  the  spine  may  cause  s^^nptoms  of 
reflected  pain  and  local  sensitiveness.  These  s^Tiiptoms  are 
increased  by  motion,  and  a  certain  amount  of  local  deformity, 
similar  in  character  to  that  due  to  sciatica,  may  be  present. 


8ACR0-ILIAC  DISEASE 


139 


SACRO-ILIAC  DISEASE. 

Tuberculous  disease  of  the  sacro-iliac  articulation  as  compared 
to  disease  of  the  spine  or  hip-joint  is  a  rare  affection  and  extremely 
so  in  childliood. 


Fig.  95. — Deformity  caused  by  per- 
sistent sciatica  of  the  right  side.  This 
attitude  is  similar  to  that  symptomatic 
of  sacro-iliac  disease. 


Fig.  96. — Sacro-iliac  disease  in  a 
child,  showing  the  extra  pelvic  abscess 
above  the  diseased  articulation. 


Symptoms.— The  symptoms  are  pain,  weakness,  limp,  and 
change  m  attitude.  The  pain  is  referred  to  the  side  of  the  pelvis 
or  radiates  over  the  buttock  or  thigh.     It  is  increased  by  jars,  by 


140       NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

turning  the  body  suddenly,  sometimes  by  coughing  or  laughing; 
and  a  peculiar  feeling  of  insecurity  and  weakness  is  sometimes 
complained  of.  As  a  rule  the  body  is  inclined  toward  the  sound 
limb;  thus  the  pelvis  is  lowered  on  the  affected  side  and  the  leg 
seems  longer  than  its  fellow.  In  the  early  stage  of  the  disease  there 
is  no  deformity  of  the  limb,  but  if  a  pelvic  abscess  forms,  the  thigh 
may  become  flexed.  Locally,  there  may  be  sensitiveness  to  pres- 
sure over  the  articulation,  or  from  within  by  rectal  examination, 
and  swelling  in  the  neighborhood  of  the  disease,  although  this  is 
usually  a  late  s^^nptom.  Pain  is  induced  by  forward  bending  of 
the  body  or  by  flexing  the  extended  limb  on  the  trunk,  movements 
that  make  the  hamstring  muscles  tense,  by  lateral  pressure  on  the 
pelvis  or  by  other  manipulation  that  moves  the  articulation. 

Abscess  finally  forms  in  the  majority  of  cases.  It  may  be  extra- 
pelvic  or  intrapelvic.  The  intrapelvic  abscess  may  present  above 
the  crest  of  the  ilium,  or  the  pus  may  pass  through  the  sciatic  notch, 
or  appear  in  the  ischiorectal  fossa,  or  break  into  the  rectum. 

Diagnosis. — Sacro-iliac  disease  may  be  mistaken  for  sciatica 
or  for  disease  of  the  /??p  or  spine.  The  freedom  of  motion  and  the 
absence  of  muscular  spasm  when  the  pelvis  is  fixed,  if  the  examina- 
tion is  carefully  conducted,  should  exclude  the  former.  And  al- 
though the  movements  of  the  spine  may  be  checked  by  muscular 
spasm  it  is  not  in  the  same  degree  as  when  the  vertebra?  are  diseased. 
The  pain  on  lateral  pressm-e,  which  is  described  as  the  most  char- 
acteristic sjTiiptom,  may  sometimes  be  simulated  closely  by  pri- 
mary acetabular  disease.  The  attitude  is  similar  to  that  of  sciatica, 
but  the  s^Tuptoms  of  local  sensitiveness  to  jars  and  to  manipulation 
are  much  more  marked. 

Prognosis. — According  to  the  statistics  the  prognosis  is  very 
unfavorable,  probably  because  the  majority  of  the  reported  cases 
were  in  adults  complicated  by  coincident  disease  of  the  lungs  and  by 
infected  and  burrowing  abscesses,  which  constitute  the  chief 
danger  of  this  form  of  tuberculous  disease. 

Treatment. — The  local  treatment  consists  in  protecting  the 
diseased  parts  from  injury.  This  in  painful  cases  requires  com- 
plete rest  of  the  individual.  Local  support  may  be  assured  by  a 
double  Thomas  hip  splint  or  spica  plaster  including  the  body  and 
both  limbs.  In  milder  cases  a  back  brace  with  a  wide  pelvic 
band  so  arranged  that  firm  pressure  may  be  made  about  the  pelvis 
supplemented  by  crutches  may  permit  ambulation. 

When  infected  abscess  is  present  radical  treatment  is  usually 
indicated.  The  articulation  should  be  freely  exposed  and  the  dis- 
eased bone  should  be  entirely  removed,  if  possible.  Intrapelvic 
abscess  should  be  drained  through  a  direct  communication,  if  pos- 
sible, in  order  to  check  the  tendency  toward  burrowing.  Disease 
of  the  sacro-iliac  joint  may  be  secondary  to  that  at  the  lumbo- 


INJURY  OF   THE  SACRO-ILIAC  ARTICULATION         141 

sacral  articulation  or  it  may  be  involved  in  other  acute  or  chronic 
processes.  Twenty-seven  cases  of  osteomyelitis  of  the  sacrum 
have  been  reported  with  20  deaths .  ^ 

INJURY  OR  WEAKNESS  OF  THE  SACRO-ILIAC  ARTICULATION. 

Symptoms  similar  to  those  of  sacro-iliac  disease  may  be  caused  by 
falls  on  the  buttock  or  pelvis  or  by  strains.  In  such  cases  there 
may  be  an  actual  injury  or  displacement  at  the  articulation.  This 
condition  was  carefully  described  by  Lee  in  1893,^  and  it  is  now 
recognized  as  of  comparatively  frequent  occurrence.  The  sacro- 
iliac articulations  are  two  joints  possessing  a  slight  movement 
backward  and  forward  on  a  horizontal  plane,  the  axis  being  the 
segment.  The  forward  inclination  of  the  sacrum  is  about  25  degrees. 
If  the\lumbarJx)rdosi^  is  lessened  the  sacrum  becomes  more  perpen- 
""dicuTar,  a  position  in  which  the  ligaments  are  relaxed.  When  the 
pelvic  inclination  is  diminished  the  spinal  muscles  work  at  a  disad- 
vantage, and  the  patient  is  inclined  to  stand  with  the  knees  flexed. 

Goldthwait,  to  whom  we  are  indebted  for  the  practical  develop- 
ment of  the  subject,  has  called  particular  attention  to  relaxation  of 
the  pelvic  articulations  caused  by  malposition  of  the  sacrum — 
which  rotating  from  its  normal  forward  inclination  to  a  more  perpen^ 
dicular  attitude  no  longer  serves  its  proper  function  as  a  wedge  to 
hold  the  pelvic  ligaments  in  proper  tension.  This  condition  is 
favored  by  pregnancy  and  consequent  relaxation  of  the  pelvic  articu- 
lations; by  long  confinement  to  bed  for  illness  or  other  cause  when 
the  lumbar  region,  being  unsupported,  loses  its  forward  inclination. 
Thus  it  may  be  assumed  that  a  lessening  of  the  lumbar  lordosis  is 
not  only  a  direct  cause  of  discomfort  but  that  it  predisposes  to 
weakness  of  the  sacro-iliac  articulation.  Under  favoring  conditions 
even  slight  injury,  often  a  strain  at  golf  or  tennis,  may  be  followed 
by  disabling  symptoms  resembling  in  some  degree  those  of  sacro-iliac 
disease,  local  discomfort  in  the  neighborhood  of  the  articulation  on 
pressure  either  direct  or  through  the  abdominal  walP  and  pain 
radiating  along  the  distribution  of  the  sciatic  plexus.  Pain  referred 
to  the  articulation  is  usually  induced  by  forward  flexion  of  the  body, 
or  by  flexing  the  extended  limb  on  the  trunk  (Kernig  sign)  and  both 
movements  are  often  restricted. 

X-ray  pictures  are  of  practically  little  value  in  diagnosis  and 
an  actual  laxity  of  the  articulation  can  rarely  be  demonstrated  except 
in  cases  incidental  to  pregnancy.  At  the  present  time  nearly  all 
cases  of  sciatica  or  pain  in  the  gluteal  or  lumbar  region  are  ascribed 
to  weakness  or  injury]  of^  the  sacro-iliac  joint,  and  fortunately  an 

1  Gaudier  and  Betain:  Rev.  de  chir.,  xxxi,  No.  8. 

^  Tr.  Am.  Orthop.  Assn.,  ii. 

=  Baer:  Johns  Hopkins  Hosp.  Bui.,  May,  1917. 


142      XOX-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE 

exact  diagnosis  is  not  essential  since  restraint  of  painful  motion  is 
the  most  efficacious  treatment. 

The  adhesive  plaster  strapping  in  broad  encircling  bands  about  the 
pelvis  and  lumbar  region,  d^a■s^'n  as  tight  as  possible,  is  a  very  effec- 
tive temporary  support.    Later  it  may  be  replaced  with  a  firm,  wide 


Fig.  97. — Fracture  of  the  pelvis;  separation  of  the  sacro-Uiae  articulation; 
impingement  of  the  transverse  process  on  the  ilium. 

"  surcingle"  about  the  pelvis,  held  in  place  by  perineal  bands.  As 
a  rule,  however,  a  light  spinal  brace  designed  to  restore  the  normal 
lordosis,  to  restrain  the  lumbar  spine,  and  to  hold  the  pelvis  firmly, 
is  indicated. 

If    actual    displacement    is    suspected,    or    normal    motion    is 


COCCYGODYNIA  143 

restrained,  correction  under  anesthesia  is  indicated.  The  patient 
lying  upon  the  back,  the  pelvis  is  fixed  by  an  attendant,  and  the 
extended  limb  is  then  gradually  flexed  upon  the  abdomen  until 
all  resistance  has  been  overcome,  the  aim  being  by  tension  on  the 
hamstrings  to  push  the  pelvis  backward  on  the  sacrum.  A  plas- 
ter spica  is  then  applied  to  hold  the  limb  extended  and  the  lumbar 
spine  in  normal  lordosis.  This  is  retained  for  two  or  more  weeks 
and  is  then  replaced  by  local  support. 

Cases  have  been  reported  in  which  the  friction  of  an  elongated 
or  displaced  transverse  process  on  the  ilium  has  induced  symptoms 
of  sacro-iliac  displacement  or  lumbago,  which  have  been  relieved 
by  its  removal. 

In  cases  of  actual  displacement  due  to  laxity  of  ligaments,  or  in 
those  cases  in  which  the  joint  is  involved  in  arthritis  deformans 
or  similar  processes,  the  operation  of  arthrodesis  or  bone  grafting 
may  be  indicated.^  "^^^ 

COCCYGODYNIA. 

Pain  or  discomfort  at  the  extremity  of  the  spine  may  be  caused 
by  injury  or  disease  of  the  coccjrs;  it  may  be  symptomatic  of  dis- 
placement, or  disease  of  the  pelvic  organs  or  tissues,  or  it  may  be 
induced  or  aggravated  by  so-called  neurotic  conditions. 

Whatever  the  causes,  the  symptoms  are  similar;  aching,  shooting 
pains  in  the  neighborhood  of  the  cocyx,  especially  while  in  the  sit- 
ting posture,  or  when  rising  from  the  sitting  position,  and  sometimes 
on  defecation  or  urination. 

Treatment. — If  the  coccyx  is  actually  bent  forward,  or  if  move- 
ment in  the  joints  is  much  restricted,  massage  and  manipulation 
between  the  thumb  and  the  finger  inserted  in  the  rectum  is  some- 
times effective. 

Yeomans'  advocates  the  injection  of  80  per  cent,  alcohol,  10  to 
20  mm.  at  intervals  of  a  week  or  more  at  the  point  of  greatest 
sensitiveness.     In  obstinate  cases  the  coccyx  should  be  removed. 

1  Arnold:  Jour.  Am.  Orfchop.  Assn.,  October,  1916. 

2  New  York  Med.  Rec,  August  22,  1914. 


CHAPTER  III. 
LATERAL  CURVATURE  OF  THE  SPINE. 

Synonyms. — Rotary  lateral  curvature;  scoliosis. 

Definition  and  General  Description. — Lateral  curvature  of  the 
spine  is  an  habitual  or  fixed  deformity  in  which  the  spine  is  inclined 
in  whole  or  part  to  one  or  the  other  side  of  the  median  line. 

By  limiting  the  term  to  habitual  deformity  one  excludes  simple 
postural  inclination  of  the  spine.  For  example,  if  one  leg  were 
considerably  shorter  than  the  other  the  pelvis  would  be  tilted  down- 
ward on  the  short  side,  and  there  would  be  a  compensatory  curva- 
ture of  the  spine  in  the  erect  attitude,  which  would  disappear  in 
the  sitting  posture.  This  accommodative  or  compensatory  incli- 
nation, and  those  of  similar  origin,  are  not,  in  the  proper  sense, 
lateral  curvatures. 

In  persistent  lateral  curvature  the  anterior  part  of  the  column 
is  more  distorted  than  are  the  spinous  processes,  because  lateral 
bending  is  always  accompanied  by  rotation  of  the  vertebral  bodies 
toward  the  convexity  of  the  curve,  the  spinous  processes  turning 
in  the  reverse  direction.  Thus  well-marked  rotation  may  be  pres- 
ent, with  but  slight  lateral  deviation  of  the  spinous  processes. 

In  the  physiological  movements  of  the  spine,  direct  lateral 
movement — that  is,  movement,  permitted  by  the  small  joints  of 
the  spine  and  by  the  lateral  compression  of  the  intervertebral 
disks — is  limited.  The  larger  movements  must  be  accompanied 
by  rotation  of  the  vertebral  bodies  by  which  this  continuous  or 
solid  part  of  the  column  is,  as  it  were,  forced  from  the  shortened 
toward  the  lengthened  side  (Fig.  98).  In  what  may  be  called 
physiological  or  simulated  lateral  curvature,  produced  by  bending  the 
body  forward  and  laterally,  the  change  in  contour  of  the  spine  would 
be  more  noticeable  if  it  could  be  observed  from  the  front  rather 
than  from  the  back,  and  as  lateral  curvature  is  simply  a  persistent 
deviation  of  the  spine,  one  of  the  so-called  static  deformities  which 
are  directly  induced  or  exaggerated  by  superincimibent  weight,  and 
improper  attitudes,  it  may  be  assumed  that  rotation  of  the  verte- 
bral bodies  often  precedes  the  lateral  distortion  that  first  attracts 
attention. 

Slight  rotation  may  not  cause  at  once  an  appreciable  degree 
of  external  distortion,  and,  although  marked  lateral  curvature 
is  necessarily  combined  with  rotation,  yet  a  slight  degree  of  direct 
lateral  inclination  may  exist  unaccompanied  by  appreciable  rota- 


DEFINITION  AND  GENERAL  DESCRIPTION 


145 


tion.  Rotation  is  usually  understood  to  imply  fixed  deformity, 
while  lateral  deviation  may  mean  simply  an  habitual  posture;  but 
it  is  far  simpler  to  consider  the  two  as  parts  of  one  distortion.  The 
important  distinction  is  between  habitual  deformity,  implying  the 
habitual  assumption  of  an  improper  attitude  in  which  the  accom- 
modative changes  in  structure  have  not  advanced  sufficiently  to 
prevent  voluntary  or  passive  correction,  and  fixed  deformity  in  which 
the  changes  in  the  bones  and  other  tissues  have  made  correction 
difficult  or  impossible.  The  evidence  of  fixed  deformity  is  rotation 
that  persists  after  the  lateral  deviation  has  been  overcome.     It 


Fig.  98. — Physiological  rotation  accompanying  flexion  and  lateral  inclination  of  the 
trunk  in  the  normal  subject. 


persists  because  the  early  and  important  changes  must  take  place 
in  the  bodies  of  the  vertebrae  upon  which  the  weight  falls,  but  there 
is  no  reason  to  believe  that  habitual  rotation  as  an  accompaniment 
of  habitual  lateral  curvature  may  not  be  corrected  if  it  be  treated 
at  the  proper  time. 

The  distribution  of  the  weight  about  the  centre  of  gravity  in 
balancing  the  body  in  the  upright  position  explains  the  character- 
istics of  lateral  curvature.  As  the  normal  contour  of  the  spine  is 
the  result  of  static  conditions,  a  change  from  this  normal  relation 
of  one  part  induces  a  corresponding  change  elsewhere.  If  there 
10 


146 


LATERAL  CURVATURE  OF   THE  SPINE 


is  a  primary  lumbar  curvature  and  rotation  to  the  left  in  the  lower 
region,  a  corresponding  lateral  deviation  and  rotation  to  the  right 
in  the  region  above  usually  develops,  thus  restoring  the  balance 
of  the  body.  This  explains  the  ordinary  S-shaped  or  double  curve 
of  scoliosis,  one  of  which  is  primary  and  the  other  secondary. 
These  curves  may  divide  the  spine  equally  or  one  may  be  long  and 
the  other  short  and  occasionally  three  distinct  curves  may  be 
present.  If  the  primary  curve  is  slight,  the  secondary  curvature 
will  be  slight  also,  and  the  primary  curve  persists  doubtless  for 


Fig.  99. — Congenital  total  scoliosis.     Compared  with  Fig.  100. 


a  time  before  compensation  appears.  In  some  instances  the 
spine  may  be  bent  laterally  into  one  long  curve,  "total  scoliosis" 
(Fig.  99).  This  is,  in  many  instances,  the  initial  stage  of  the  ordi- 
nary type  of  scoliosis,  the  long  curve  being  afterward  divided.  In 
childliood  total  scoliosis  is  often  combined  with  general  posterior 
curvature,  and  it  is  peculiar  in  that  the  torsion  of  the  vertebrse  may 
be  toward  the  concave  instead  of  the  convex  side,  the  torsion  repre- 
senting probably  the  early  stages  of  the  secondary  or  compensatory 


curve. 


DEFINITION  AND  GENERAL   DESCRIPTION  147 

It  has  been  stated  that  deformity  of  one  part  of  the  spine  is 
usnally  balanced  by  deformity  of  another.  This  enables  the  trunk 
to  hold  the  erect  posture,  and  it  restores  its  general  symmetry. 
If,  however,  a  long  lateral  or  long  posterior  curvature  persists,  the 
weight  can  be  balanced  only  by  swaying  the  entire  body  on  the 
pelvis,  in  the  direction  opposed  to  the  distortion.  This  restores 
the  balance,  but  not  the  symmetry  (Fig.  112). 

Rotation  and  Lateral  Deviation. — Fixed  rotation  of  the  spine 
carries  with  it,  of  course,  all  the  parts  that  are  attached  to  it. 
When  the  patient  stands  in  the  erect  attitude  the  simple  lateral 
distortion  is  most  noticeable  (Fig.  99),  but  when  the  body  is  bent 
forward  the  torsion  of  the  trunk  becomes  the  prominent  deformity 


Fig.   100. — Congenital  total  scoliosis.     The  rotation  is  much  greater  than  the  lateral 
deviation.     Compare  with  Fig.  99. 

(Fig.  100).  If  the  thoracic  region  is  involved,  the  ribs  on  the  side 
toward  which  the  spine  is  rotated  project  backward,  and  on  the 
other  side  of  the  spine  there  is  a  corresponding  flatness  or  depression. 
The  projection  of  the  ribs  due  to  the  distortion  of  the  thorax  is  far 
more  noticeable  than  is  the  simple  twisting  of  the  free  portions  of 
the  spine  in  the  neck  or  loins;  and  in  these  regions  the  projecting 
transverse  processes  covered  by  the  thick  layers  of  muscles,  yet 
unaccompanied  by  marked  lateral  diviation,  may  cause  mistakes  in 
diagnosis.  In  the  cervical  region,  for  example,  as  an  accompaniment 
of  acute  torticollis,  the  projection  may  be  mistaken  for  abscess; 
and  in  the  lumbar  region  it  has  been  mistaken  for  a  new  growth 
attached  to  the  spine. 

Although  persistent  lateral  curvature   of  the   spine  is  always 


148  LATERAL  CURVATURE  OF   THE  SPINE 

accompanied  by  rotation,  the  degree  of  rotation  does  not  always 
correspond  to  that  of  the  more  evident  lateral  deviation.  In  the 
instance  cited,  rotation  in  the  lumbar  region,  so  extreme  as  to 
simulate  an  abnormal  gro^^i:h,  may  be  present  with  but  slight 
lateral  distortion  of  the  trunk;  while  in  other  instances  the  body 
appears  to  be  greatly  displaced  to  one  side,  although  there  may  be 
comparatively  little  fixed  rotation.     Again,  as  has  been  stated,  the 


Fig.    101. — Primary  lumbar  curvature  to  the  left.     A  "flat-back"  marked  rotation 
vrith.  but  slight  lateral  curvature. 

lateral  deviation  of  the  trunk  is  usually  more  noticeable  than  the 
rotation,  which  in  the  slighter  grades  of  deformity  is  only  made 
apparent  when  the  patient  is  bent  forward  so  that  the  back  may 
be  inspected  in  the  horizontal  position.  It  may  be  noted,  also, 
that  the  degree  of  habitual  lateral  distortion  of  the  body  does 
not  correspond  to  the  degree  of  fixed  distortion.  One  individual, 
by  voluntary  eflort,  may  practically  conceal  advanced  deformity, 


DEFINITION  AND  GENERAL  DESCRIPTION  149 

while  another  who  makes  no  effort  to  correct  the  improper  pos- 
ture appears  to  be  greatly  distorted,  although  the  fixed  changes 
may  be  very  slight. 

The  effects  of  the  deformity,  both  general  and  local,  depend 
upon  its  situation  and  its  degree.  In  one  instance  it  may  be  so 
slight  as  to  pass  unnoticed,  and  in  another  the  distortion  may 
equal  that  characteristic  of  Pott's  disease  (Fig.  102).  If  compen- 
sation is  perfect — that  is,  if  the  deformity  is  equally  distributed  on 
either  side  of  the  median  line — the  general  symmetry  of  the  body 


Fig.   102. — Scoliosis  with  marked  posterior  deformity. 

may  be  but  slightly  disturbed.  Or,  if  the  compensation  for  the  pri- 
mary deformity  of  the  lumbar  region  is  distributed  throughout  the 
remainder  of  the  spine,  noticeable  distortion  may  be  insignificant, 
but  when  there  is  a  long  curve  involving  the  thoracic  region  the 
lateral  and  posterior  displacement  cannot  be  concealed  (Fig.  103). 
Changes  in  the  Anteroposterior  Contour. — Lateral  distortion  in- 
volves also  secondary  changes  in  the  anteroposterior  outline  of 
the  spine.  If  the  distortion  is  marked  the  stature  is  shortened, 
especially   when    the    anteroposterior    curves    are    increased.     In 


150  LATERAL  CURVATURE  OF   THE  SPINE 

■general,  one  may  recognize  two  types  of  lateral  curvature:  one 
in  which  the  back  is  flatter  than  normal,  in  which  the  antero- 
posterior curves  are  diminished,  and  another  in  which  they  are 
increased.  It  has  been  stated  in  the  account  of  Pott's  disease  that 
deformity  in  one  segment  of  the  spine  always  caused  a  change  in 
the  contour  of  the  spine  as  a  whole,  that  an  obliteration  or  a  lessen- 
ing of  the  concavity  of  the  lumbar  region  was  accompanied  by  a 
corresponding  flattening  of  the  normal  dorsal  kyphosis.     On  the 


Fig.   103. — Scoliosis  with  extreme  lateral  deviation. 

other  hand,  that  an  increase  in  the  backward  projection  of  the  dor- 
sal region  caused  an  increased  concavity  below.  The  variations 
in  the  anteroposterior  contour  of  the  spine  in  lateral  curvature  may 
be  accounted  for  in  the  same  manner.  In  one  the  instance  the  pri- 
mary deformity  is  of  the  lower  region,  and  with  its  accompanying 
backward  twist  of  the  vertebral  bodies  it  lessens  the  lumbar  lordo- . 
sis  and  tends  to  flatten  the  back  (Fig.  101).  If,  on  the  other  hand, 
the  deformity  begins  in  the  thoracic  region,  the  primary  effect  is 
to  increase  the  backward  projection,  and  this  in  turn  tends  to  exag- 


PATHOLOGY 


m 


gerate  the  lumbar  lordosis  (Fig.  104).  Thus  the  shortening  of  the 
trunk  in  the  lumbar  region  caused  by  the  lateral  deviation  may  be 
to  a  certain  extent  compensated  in  the  first  instance,  while  in  the 
other  both  the  primary  and  secondary  distortions  tend  to  reduce 
the  height. 

The  "High"  Shoulder  and  the  "High"  Hip.— If  the  convexity 
of  the  primary  curve  is,  for  example,  to  the  left  in  the  lumbar 
region  the  trunk  is  displaced  somewhat  to  the  left,  consequently 
the  right  pelvic  crest  becomes  ab- 
normally prominent,  a  prominence 
that  is  usually  mistaken  for  an 
elevation,  *and  in  compensation 
there  is  a  corresponding  twist  in 
the  opposite  direction  above.  The 
spine  bending,  and  at  the  same 
time  rotating  toward  the  right, 
carrying  with  it  the  ribs,  raises  the 
shoulder  and  makes  the  scapula 
prominent.  Thus  it  is  that  in  the 
ordinary  S-shaped  curve  the  high 
shoulder  and  the  prominent  hip 
appear  usually  upon  the  same  side 
of  the  body.  But  in  less  regular 
varieties  of  distortion,  when,  for 
example,  there  is  marked  general 
lateral  deviation  of  the  trunk  as  a 
whole,  the  high  shoulder  may  be 
on  the  opposite  side  (Fig.  113). 
It  is  probable  that  the  primary  cur- 
vature is  in  most  instances  to  the 
left  in  the  lumbar  region,  the 
compensation  to  the  right  appear- 
ing at  a  later  time.  This  is  cer- 
tainly true  of  the  milder  types  of 
postural  curvature. 

Pathology.  —  Lateral  curvature 
of  the  spine  is  a  deformity,  not  a 
disease,  nor  is  it  ordinarily  an 
effect  of  disease.  For  this  reason 
the  description  of  the  pathology  which  is  merely  a  more  detailed 
account  of  the  deformity  and  of  its  secondary  effects  upon  the 
trunk  and  its  contents  may,  for  convenience,  precede  the  discussion 
of  the  etiology. 

In  such  a  description  one  must  consider  the  trunk  as  a  whole, 
its  central  column  bent  and  twisted  and  displaced  in  which  each 
component  segment  shares  in  the  general  distortion.  The  verte- 
bra at  the  apex  of  each  curve  shows  the  greatest  change.     If  the 


Fig.  104. — High  dorsal  deformity. 


152 


LATERAL  CURVATURE  OF   THE  SPINE 


rotation  and  lateral  deviation  is  to  the  right  the  vertebral  body  is 
somewhat  wedge-shaped,  the  apex  of  the  wedge  being  directed  back- 
ward and  to  the  left.  Its  lateral  diameter  is  increased  and  the 
superior  and  inferior  margins  at  the  narrow  side  project,  increasing 


its  lateral  concavity  (Fig.  108).  Similar  accommodative  changes, 
although  less  marked,  are  to  be  found  in  the  articular  processes  and 
in  the  laminae;  in  fact,  all  the  parts  on  the  concave  side  are  broad- 
ened, shortened,  and  lessened  in  A'ertical  diameter  as  compared  with 


PATHOLOGY 


153 


those  on  the  convex  side  of  the  spine.  These  changes  affect  the 
shape  of  the  neural  canal,  which  becomes  somewhat  ovoid  in  out- 
line, the  base  being  directed  toward  the  convexity  of  the  curve 
(Fig.  109).  In  the  vertebrae,  included  in  the  compensatory  curva- 
ture, the  deformities  are  reversed,  and  the  intermediate  segment 
show  the  transitional  changes  between  the  two  extremes.  The 
intervertebral  disks  become  wedge-shaped  also  and  atrophied  on 
the  shortened  side,  the  changes  in  these  softer  tissues  preceding, 
undoubtedly,  those  in  the  bones.  The  articulations  of  the  verte- 
brae become  changed  in  shape  and  position  in  the  general  adaptation 
to  the  deformity  and  the  ligaments  are  shortened  or  lengthened 
according  to^heir  relation  to  the  distortion. 


Fig.  108. — Scoliotic  vertebrae.     (Hoffa.) 

On  section  the  internal  structure  of  the  vertebrae  shows  the 
same  adaptive  changes  that  are  evident  on  the  exterior.  In  the 
narrowed  parts  of  the  bones  that  bear  the  weight  the  tissue  is 
thick  and  compact,  on  the  opposite  side  it  is  attenuated  and 
atrophied. 

The  mobility  of  the  spine  is  lessened  by  these  changes  in  its 
shape  and  structure,  primarily  by  the  distortion,  secondarily  by 
the  shortening  of  the  tissues  on  the  concave  side,  by  the  irregu- 
larities of  the  vertebral  bodies,  by  the  interference  of  the  newly 


154 


LATERAL  CURVATURE  OF   THE  SPINE 


formed  or  transformed  bone  which  is  thrown  out  about  the  margins 
of  the  vertebrae  and  the  articular  processes,  and  by  ossification  of 
the  periosteum  and  hgamentous  coverings  of  the  adjacent  bones. 
Thus,  in  fixed  deformity  there  may  be,  at  the  points  of  greatest 
distortion,  practical  anchylosis.  The  muscles  of  the  spine,  both 
intrinsic  and  extrinsic,  undergo  adaptative  changes,  and,  as  a  rule, 
they  are  relatively  weak. 

The  most  important  of  the  secondary  deformities  of  lateral 
curvature  is  that  of  the  thorax.  This  is  somewhat  difficult  to 
describe,  because  the  distortion  of  the  dorsal  vertebrse  does  not  afi^ect 
the  thorax  equally;  thus,  it  is  not  twisted  as  a  whole,  nor  flexed 
as  a  whole.     The  nature  of  the  deformity  may  be  better  under- 


FiG.   109. — Change  in  shape  of  the  spinal  canal,  broader  on  the  convex  side.      (Hoffa.) 


stood  by  considering  the  sternum  as  a  fixed  point;  this,  as  a  matter 
of  fact,  it  is,  as  compared  with  the  spine.  At  the  apex  of  the  con- 
vexity of  the  curve  the  ribs  are  drawn  sharply  backward;  their 
angles  project  by  the  side  of  and  beyond  the  spinous  processes, 
sometimes  covering  and  concealing  them,  and  the  lateral  convexity 
of  the  chest  is  diminished  or  lost.  On  the  opposite  side  the  back 
is  broadened  and  flattened.  The  effect  of  the  rotation  is  to  dimin- 
ish the  capacity  of  the  chest  on  the  convex  side  and  to  increase  that 
of  the  concave  side  (Fig.  110).  On  the  convex  side  the  ribs  are 
elevated  and  their  inclination  is  increased.  On  the  concave  side 
the  intercostal  spaces  are  narrowed  and  the  inclination  is  lessened 
(Fig.  107).  The  anteroposterior  diameter  of  the  chest  is  increased 
or  diminished  according  to  the  change  in  the  anteroposterior  con- 


PATHOLOGY  155 

tour  of  the  spine.  If  the  dorsal  kyphosis  is  exaggerated  the  effect 
is  to  deepen  the  chest  (Fig.  102) ;  if  it  is  diminished,  the  diameter  of 
the  thorax  is  correspondingly  lessened. 

The  cervical  section  of  the  spine  except  in  cases  of  congenital 
malformation  is  not  often  involved,  to  a  marked  degree  at  least, 
in  the  lateral  deformity.  But  in  extreme  cases,  in  which  the  neck 
and  head  are  habitually  distorted,  there  may  be  accommodative 
changes  in  the  skull  similar  to  those  induced  by  persistent  torticollis. 

At  the  other  extremity  of  the  spine  the  pelvis  is  not,  as  a  rule, 
markedly  deformed  except  in  cases  due  directly  to  rachitis.  In 
some  instances  the  oblique  diameter,  opposed  to  the  convexity  of 
the  lumbar  deformity,  may  be  increased,  and  if  the  lateral  deviation 
of  the  lumbar  spine  is  extreme  the  pelvis  may  be  so  tilted  that  the 
limb  on  the  elevated  side  becomes  apparently  shorter  than  its 
fellow. 


Fig.   110. — Deformity  of  the  thorax  in  scoliosis.     (Hoffa.) 

In  changes  that  have  been  described  the  contents  of  the  trunk 
participate  to  a  greater  or  less  degree.  The  lung  on  the  convex 
side  is  compressed  by  the  distorted  ribs  and  by  the  displaced 
vertebral  bodies.  The  heart  may  be  displaced  laterally  or  in  other 
directions  according  to  the  character  of  the  deformity,  and  the  blood- 
vessels are  changed  in  direction,  and,  it  may  be,  altered  in  calibre. 
In  those  cases  in  which  the  thorax  is  markedly  distorted  the  effect 
is  similar  to  that  of  the  deformity  of  Pott's  disease;  respiration  is 
shallow  and  rapid,  the  pulse-rate  is  usually  increased,  and  other 
evidences  of  interference  with  the  vital  functions  may  be  apparent. 
The  abdominal  organs  are  affected,  doubtless,  in  a  similar  manner, 
but  symptoms  due  to  this  cause  are  not,  as  a  rule,  as  clearly  marked. 

Bachman^  investigated  the  secondary  changes  induced  by  severe 

1  Bachmann:  Die    Veranderungen    an    den    inneren    Organen    bei    hochgradigen 
Skoliosen  und  Kyphoskoliosen,  Bibliotheca  Medica,  1900,  Ab.  D.  1,  H.  4. 


156  LATERAL  CURVATURE  OF   THE  SPINE 

scoliotic  deformity  coming  under  his  observation  in  the  pathologi- 
cal institute  of  Breslau.  In  91.3  per  cent,  of  the  subjects  defect  or 
disease  of  the  circulatory  apparatus,  and  in  99.1  per  cent,  of  the 
respiratory  organs  was  observed. 

Etiology. — Relative  Frequency. — Lateral  curvature  of  the  spine 
is  one  of  the  most  common  of  deformities.  In  a  period  of  years 
3252  cases  were  recorded  in  the  out-patient  department  of  the  Hos- 
pital for  Ruptured  and  Crippled,  a  number  only  exceeded  by  that 
of  bow-legs,  of  which  5030  cases  were  treated  during  the  same 
time. 

The  relative  frequency  of  lateral  curvature  among  children  in 
general  is  illustrated  by  the  statistics  of  Drachmann,  who  found 
among  28,125  school-children  (16,789  boys,  11,386  girls)  of  Den- 
mark 368  cases  of  scoliosis  (1.3  per  cent.),  and  those  of  Scholder, 
Werth,  and  Combe,^  who  found  571  cases  of  lateral  curvature 
among  2314  school-children  of  Switzerland  (2-1.6  per  cent.),  a  dis- 
crepancy that  is  somewhat  difficult  to  explain. 

Sex. — Lateral  curvature  of  the  spine  is  far  more  common  among 
females  than  males.  Of  the  3252  cases  referred  to,  2554  (78.5  per 
cent.)  were  in  females  and  698  (21.4  per  cent.)  were  in  males. 

The  lowest  percentage  of  males  in  any  one  of  the  fifteen  years 
was  14.8,  the  highest  25.1.  This  proportion  of  one  male  to  four 
females  is  somewhat  larger  than  in  the  smaller  groups  of  cases 
reported  by  other  observers. 

The  unequal  distribution  of  the  deformity  between  the  sexes 
is  of  great  interest  as  bearing  on  the  question  of  etiology;  espe- 
cially so  as  in  the  cases  that  develop  in  early  childhood,  sex  appears 
to  exercise  practically  no  influence.  It  has  been  suggested  that 
curvature  of  the  spine  in  a  girl  is  looked  upon  with  more  solicitude 
by  the  mother  than  is  the  same  deformity  in  a  boy,  therefore  more 
girls  are  brought  for  treatment.  There  may  be  some  basis  for  this 
argument,  for  it  is  certain  that  distortions  of  the  lower  extremities 
are  considered  of  greater  importance  in  male  than  in  female  children, 
because  of  the  concealment  to  be  afforded  by  the  skirts,  if  the  de- 
formity is  not  outgrown.  But  granting  that  statistics  are  somewhat 
unreliable,  there  can  be  no  doubt  but  that  this  deformity  is  far  more 
common  among  girls  than  boys  and  that  the  disproportion  may  be 
explained,  in  great  part  at  least,  by  the  differences  in  dress  and  in 
manner  of  life. 

Age. — One  thousand  two  hundred  and  ninety-nine  (39.9  per 
cent.)  of  the  3252  patients  referred  to  were  less  than  fourteen 
years  of  age;  1576  (48.4  per  cent.)  were  between  fourteen  and 
twenty-one;  377  (11.6  per  cent.)  were  more  than  twenty-one 
years  of  age.  These  statistics  simply  show  the  age  of  the  patients 
at  the  time  treatment  was  sought,  and  they  are  of  little  value  as 

1  Annals  Suisses  d' Hygiene  Scolaire,  1901. 


ETIOLOGY 


157 


an  indication  of  the  age  at  which  deformity  might  have  been  de- 
tected had  it  been  looked  for. 

There  is  no  reason  to  suppose  that  lateral  curvature  of  the 
spine  differs  in  its  etiology  from  similar  deformities  of  other  parts, 
except  insofar  as  each  region  of  the  body  is  more  or  less  susceptible 
to  deforming  influences  at  one  time  than  another. 


Fig.  111. — Scoliosis  of  a  severe  type,  showing 
the  general  distortion  of  the  spine  and  of  the 
individual  vertebrae.  (Nicoladoni.) 


Fig.  112. — Scoliosis  of  slight 
degree,  showing  the  change  in  the 
vertebral  bodies.     (Nicoladoni.) 


For  example,  rhachitic  deformities  of  the  upper  extremities 
practically  never  develop  except  in  infancy,  and  they  begin  to 
correct  themselves  when  the  erect  posture  is  assumed  or  at  the 
very  time  when  distortions  of  similar  origin  of  the  lower  extremi- 
ties appear  or  increase.  When  deformities  of  this  class,  whether 
of  the  spine  or  limbs,  appear  in  later  childhood  or  adolescence  it 
may  be  assumed  that,  in  many  instances  at  least,  the  tendency 
toward  the  particular  deformity,  or  even  a  slight  degree  of  deformity, 


158  LATERAL   CURVATURE  OF   THE  SPIXE 

was  acquired  at  an  early  age,  that  it  remained  latent  until  conditions 
appeared  which  favored  its  further  development.  This  point  is 
illustrated  by  the  statistics  of  Eulenburo;  of  1000  cases  of  lateral 
curvature  analyzed  with  reference  to  the  inception  of  the  deformity. 

Between  Ijirth  and  the  sixth  year 78 

Between  the  sixth  and  seventh  years 216 

Between  the  seventh  and  tenth  years 564 

Between  the  tenth  and  fotirteenth  years 107 

After  the  fourteenth  year 35 

1000 

It  will  be  noted  that  but  142  (14.2  per  cent.)  of  these  patients 
were  more  than  fourteen  years  of  age  as  contrasted  with  the  sta- 
tistics of  the  Hospital  for  Ruptured  and  Crippled,  in  which  60  per 
cent,  were  beyond  this  age. 

In  2000  cases  reported  by  Roth  the  deformity  was  first  noticed: 

Between  one  and  five  years 34 

Between  six  and  ten  years 190 

Between  eleven  and  fifteen  years 468 

Between  sixteen  and  twenty  years 209 

Between  twenty-one  and  thirty  years 78 

Between  thirty-one  and  forty  years 17 

Over  forty-one  years 4 

1000 

Dr.  ^Yalte^  Truslow,  who  for  several  years  had  the  immediate 
charge  of  the  treatment  of  lateral  curvature  at  the  Hospital  for 
Ruptured  and  Crippled,  prepared  for  me  statistics  of  a  number 
of  the  cases  which  illustrate  the  same  point. 

But  44  of  the  181  patients  (22.6  per  cent.)  were  more  than  thir- 
teen years  of  age  at  the  time  when  the  deformity  was  first  noticed, 
although  nearly  50  per  cent,  were  older  than  this  when  treatment 
was  applied  for.  In  the  first  table  it  wiU  be  noted  that  of  the  38 
patients  who  were  ten  years  of  age  or  less,  15,  or  about  40  per  cent., 
were  males.  Of  25  of  the  37  cases  in  which  the  deformity  attracted 
attention  at  or  before  the  sixth  year  rhachitis  was  the  apparent 
cause. 

Lateral  curvature  of  the  spine  is  one  of  the  penalties  of  the  erect 
posture,  and  the  force  of  gravity  must  be  considered  both  as  a 
predisposing  and  as  an  exciting  cause  of  the  deformity. 

The  more  direct  tendency  of  the  force  of  gravity  is  to  cause  the 
body  to  incline  forward  and  to  increase  the  posterior  curvature  of 
the  spine,  but  whenever  there  is  a  persistent  inclination  of  the  spine 
to  one  or  the  other  side  this  inclination  is  likely  to  be  increased  to 
deformity  under  favoring  conditions.  These  favoring  conditions 
would  include  general  weakness  from  any  cause;  overwork  that 
may  induce  fatigue,  and  all  factors,  mechanical  or  otherwise,  that 
may  add  to  the  difficulty  of  holding  the  trunk  erect  under  the  pres- 
sure of  the  superincumbent  weight. 


ETIOLOGY  159 

Although  it  is  not  difficult  to  suggest  the  predisposing  causes 
of  lateral  curvature,  it  is  by  no  means  as  easy  to  point  out  the 
direct  cause  of  the  original  inclination  of  the  spine  to  one  or  the 
other  side  of  the  median  line  that  is  the  first  step  toward  fixed 
deformity.  In  a  certain  number  of  cases,  however,  the  relation 
between  cause  and  effect  is  sufficiently  evident,  and  these  causes 
may  be  enumerated  before  considering  the  larger  class  in  which 
the  etiology  is  more  obscure. 

1.  Lateral  curvature  secondary  to  deformity  of  other  parts. 

2.  Static  or  compensatory  deformity. 

3.  Deformity  secondary  to  disease  of  the  nervous  system. 

4.  Deforijiity  secondary  to  disease  of  the  thoracic  organs. 

5.  Incidental  deformity. 

6.  Deformity  due  to  occupation. 

7.  Congenital  deformity. 

8.  Rhachitic  deformity. 

1.  Lateral  Curvature  Secondary  to  Deformity  Elsewhere. 
— (a)  Lateral  curvature  of  the  spine  may  be  a  compensatory  effect 
of  torticollis,  either  congenital  or  acquired,  {h)  It  may  be  induced 
by  distortion  of  the  lower  extremities.  For  example,  fixed  adduc- 
tion of  the  thigh  necessitates  an  upward  tilting  of  the  pelvis  when- 
ever the  limb  is  brought  into  the  median  line,  whether  the  patient 
is  standing,  sitting,  or  lying;  and  this  deformity  when  extreme  may 
induce  lateral  curvature  even  in  bed-ridden  patients. 

2.  Compensatory  Deformity. — The  same  effect  is  sometimes 
observed  in  certain  instances  of  inequality  of  the  length  of  the 
Jower  extremities.  In  the  erect  posture  the  pelvis  i^tilted  downward 
on  one  side,  an  inclination  which  requires  lateral  inclination  and  if 
considerable,  rotation  of  the  spine  as  well.  Simple  inequality  of 
the  limbs  is  an  occasional  but  not  a  common  cause  of  fixed  deformity, 
because  its  influence  ceases  in  the  sitting  and  reclining  postures, 
and  because  the  inequality  is  so  often  compensated,  if  it  is  extreme, 
by  walking  on  the  toe  or  by  raising  the  sole  of  the  shoe. 

An  increase  in  the  length  of  a  limb,  such  as  may  be  caused  by 
a  fixed  equinus  of  the  foot,  seems  to  have  more  influence  in  causing 
secondary  deformity  than  does  shortening,  because  no  attempt  is 
made  to  compensate  for  the  inequality. 

3.  Lateral  Curvature  Secondary  to'  Paralysis. — Lateral 
deformity  of  the  spine  may  be  caused  indirectly  by  a  number  of 
distinct  diseases  of  the  nervous  system,  but  in  this  connection  only 
one  need  be  considered — anterior  poliomyelitis.  It  may  induce 
deformity  by  distortion  of  a  lower  extremity  or  by  inequality  in  the 
length  of  the  limbs  due  to  retardation  of  growth.  It  may  predis- 
pose to  deformity  by  the  general  weakness  that  it  causes,  and  by  the 
postures  assumed,  or  the  trunk  may  be  unbalanced  by  loss  of  func- 
tion in  one  of  the  upper  extremities,  but  the  more  extreme  cases  of 
deformity  are  caused  by  unilateral  paralysis  of  the  muscles  of  the 


160 


LATERAL  CURVATURE  OF   THE  SPINE 


trunk.  As  a  result  the  expansion  of  one  side  of  the  thorax  is  inter- 
fered with  and  the  unaffected  or  less  affected  side  taking  on  in- 
creased activity  develops  at  the  expense  of  the  disabled  part. 
Thus  the  convexity  of  the  curve  is  usually  toward  the  sound  side. 
4.  Lateral  Curvature  Secoxdary  to  Disease  within  the 
Thoracic  Walls. — The  most  common  cause  of  deformity  of  this 
class  is  persistent  empyema.  The  lung  is  primarily  compressed  by 
the  effused  fluid,  and  its  function  is  finally  impaired  or  abolished 


Fig. 


114. — Scoliosis  secondary  to  Pott'i 
disease  in  earljr  childhood. 


Fig.  113. — Scoliosis  in -a  patient 
nineteen  years  of  age  caused  by 
empyema  in  infancy. 

by  the  adhesions  that  form  between  it  and  the  chest  wall,  as  well  as 
by  the  extension  of  the  disease  to  its  structure.  As  a  result  the 
side  of  the  chest  is  retracted  while  the  function  of  the  imaffected 
Imig  is  increased  (Fig.  113).  Thus,  as  in  paralysis,  the  spine  curves 
with  the  con^'exity  toward  the  active  side. 

Other  affections  of  the  lungs  that  interfere  with  the  function 
of  one  side  may  induce  lateral  curvature,  but  the  influence  is  less 
marked  and  direct  than  in  empyema.^ 


1  See  Anterior  Poliomyelitis. 


ETIOLOGY 


161 


5.  Incidental  Lateral  Curvature. — Lateral  curvature  may 
be  caused  by  direct  injury  or  by  disease  of  the  spine;  for  example, 
by  fracture  or  by  Pott's  disease,  or  by  other  organic  affections 
of  the  spine  (Fig.  114).  Distortion  symptomatic  of  sacro-iliac 
disease,  or  the  more  marked  deformity  caused  by  sciatic  or  lumbar 
neuritis  (Fig.  95),  may  if  persistant  finally  induce  slight  permanent 
deformity,  but  such  cases  hardly  deserve  special  consideration. 


Fig.   115. — Congenital  scoliosis 


Fig.  116. — Rhachitic  scoliosis. 


6.  Lateral  Curvature  due  to  Occupation. — Lateral  curva- 
ture of  a  mild  degree  is  incidental  to  certain  occupations  that  re- 
quire habitual  inclination  of  the  body.  It  is  said  to  be  very  common 
among  stone-cutters,  for  example.  Such  deformity  developing 
after  the  growth  of  the  body  has  been  attained  is  of  interest  as  throw- 
ing light  upon  the  etiology  of  the  ordinary  form  of  lateral  curvature. 
For  if  habitual  attitudes  can  thus  change  the  contour  of  the  devel- 
oped spine,  it  is  evident  that  similar  postures,  though  far  less  con- 
stant, may  influence  the  spine  of  a  growing  child,  particularly  in 
one  predisposed  to  such  distortion. 
11 


162 


LATERAL  CURVATURE  OF   THE  SPINE 


7.  Congenital  Lateral  Curvature.— Congenital  scoliosis  may 
occur  in  infants  otherwise  normal  due  apparently  to  a  constrained 


Fig.  117. 


-Congenital  lateral  curvature  caused  by  malformation  of  the  lower  lumbar 
and  sacral  vertebras.     There  are  thirteen  ribs. 


ETIOLOGY 


163 


attitude  before  birth.  It  is  usually  associated,  however,  with  other 
defects  or  deformities,  for  example,  with  cervical  ribs,  elevation 
of  the  scapula  and  the  like.  The  deformity  may  be  apparent  at 
birth  or  it  may  not  be  observed  until  later  years,  when  examination 
by  the  .r-rays  shows  supernumerary,  deficient  or  fused  vertebrae 
and  the  like^Figs.  117,  118  and  119). 

8.  Rhachitic  Lateral  Curvature. — Rhachitis  predisposes  to 
deformity  of  all  parts  of  the  body  by  lessened  resistance  of  all  the 
tissues.  As  is  well  known,  the  common  deformities  from  this  cause 
are  the  so-called  rhachitic  kyphosis  that  develops  in  the  sitting 
child,  and  the  distortions  of  the  lower  extremities  in  those  who  stand 


Fig.  118. 


-Congenital  lateral  curvature  caused  by  malformation  of  the  upper  dorsal 
vertebrae.     Several  ribs  are  absent. 


and  walk.  Lateral  curvature  of  the  spine  sometimes  accompanies 
the  kyphosis  in  those  who  do  not  walk,  or  it  may  e'xist  independently 
of  it.  The  lateral  inclination  is  induced  doubtless  by  the  manner  of 
sitting  or  by  the  manner  in  which  the  child  is  supported  on  the 
mother's  arm;  for  at  this  period  of  rapid  growth  and  increased  sus- 
ceptibility to  deforming  influences,  even  slight  and  temporary 
causes  of  this  nature  may  be  sufficient  to  induce  the  distortion 
(Fig.  116).  Again,  when  the  child  begins  to  walk,  the  tilting  of  the 
pelvis  due  to  distortion  of  the  limbs,  for  example,  to  unilateral  knock- 
knee,  may  also  serve  to  disturb  the  equilibrium  of  the  body  and  thus 
to  induce  lateral  distortion. 


164 


LATERAL  CURVATURE  OF   THE  SPINE 


How  common  rhachitic  lateral  curvature  may  be  it  is  impossible 
to  say,  but  if  all  rhachitic  infants  and  children  were  carefully 
examined  this  deformity  would  be  discovered  in  many  instances  in 
which  its  existence  had  not  been  suspected. 

Mayer^  examined  220  rhachitic  children  with  reference  to  this 
point,  and  in  all  but  3  found  scoliotic  deformity.  This  is  not  in 
accord  with  my  experience,  but  I  am  convinced  that  rhachitis  is  of 
far  greater  importance  in  the  etiology  of  lateral  curvature  of  the 


Fig.   119. — Congenital  lateral  curvature.     (See  Fig.  92.) 

spine  than  is  generally  believed,  and  that  the  larger  proportion  of 
the  severe  and  intractable  cases  may  be  traced  to  this  cause.  As 
has  been  mentioned,  rhachitic  scoliosis  is,  practically  speaking, 
equally  divided  between  the  sexes. 

In  about  15  per  cent,  of  the  cases  under  treatment  by  Trus- 


1  Bull,  med.,  Paris,  June  15,  1901. 


ETIOLOGY 


165 


low  the  influence  of  one  or  more  of  the  causes  that  have  been  enu- 
merated seemed  to  be  apparent,  viz. : 

Congenital  deformity 2 

Torticollis 2 

Empyema 4 

Anterior  poliomyelitis ...  3 

Inequality  of  the  legs  of  more  than  half  an  inch 6 

Rachitis 13 

Total      . 30 

In  the  remaining  85  per  cent,  of  the  cases  the  direct  cause  of  the 
deformity  was  uncertain. 

Hereditary  Influence. — By  many  writers  the  influence  of  hereidty 
is  considered  an  important  factor  in  the  etiology.  That  there 
is  such  an  influence,  predisposing  to  disease  as  well  as  to  deformity, 
is  undoubted,  but  it  is  very  difficult  to  establish  its  connection 


Fig.   120. — Posture  induced  by  improper  desk  and  chair.      (Scudder.) 


with  ordinary  cases.  In  11  of  201  cases  lateral  curvature  was 
present  in  either  the  father  or  mother  of  the  patient;  and  in  17 
others  a  brother  or  sister  of  the  patient  was  deformed  in  a  similar 
manner.  In  1000  cases  reported  by  Roth,  276  had  blood  relations 
suffering  from  scoliosis  and  there  were  seven  families  in  which  three 
or  more  members  were  affected.^ 

1  British  Med.  Jour.,  September  2,  1911. 


166  LATERAL  CURVATURE  OF   THE  SPINE 

Occupation. — As  occupation  may  induce  deformity  in  the  adult, 
one  looks  naturally  to  occupation  as  a  factor  in  the  causation  of 
lateral  curvature  in  childhood.  Occupation  in  this  class  implies 
school,  and  it  is  well  known  that  fatigue  during  school  hours  may  in- 
duce improper  postures,  especially  if  the  chair  is  unsuitable  or  un- 
comfortable. The  influence  of  habitual  posture  is  indicated  in  the 
statistics  of  lateral  curvature  among  school-children  recorded  by 
Scholder,  Werth,  and  Combe,^  the  proportion  of  deformity  steadily 
rising  from  the  lower  to  the  higher  classes  (Figs.  120  and  121). 
Under  the  influence  of  constantly  recurring  fatigue  an  improper 
attitude  is  likely  to  become  habitual,  its  character  being  influenced 


Fig.   121. — Posture  induced  by  improper  chair.     (Scudder.) 

by  the  arrangement  of  the  light  or  by  the  shape  of  the  seat  or  desk. 
As  Abbott  has  pointed  out,  the  most  perfect  simulation  of  lateral 
curvature  is  the  attitude  of  a  child  writing  at  a  desk  in  which  for- 
ward and  lateral  inclination  are  combined  with  torsion.  When  a 
habit  of  posture  has  been  acquired  it  is  likely  to  persist  when  the 
sitting  posture  is  assumed  elsewhere  than  at  school,  and  the  greater 
liability  of  girls  to  the  deformity  may  be  explained  in  part  by  the 
fact  that  they  sew,  or  read,  or  play  on  the  piano  when  boys  are 
usually  engaged  in  active  exercises. 

In  400  cases  of  lateral  curvature  under  treatment  at  the  Hos- 

1  Bull,   med.,   Paris,   June   15,    1901. 


ETIOLOGY  167 

pital  for  Ruptured  and  Crippled,  the  occupation  and  habits  that 
may  have  influenced  the  deformity  were  recorded: 

Occupation: 

School 285 

Factory 19 

Clerk 13 

Domestic 8 

Millinery,  dressmaking,  etc 8 

Messenger 3 

Housewife 3 

Teacher 2 

No  occupation ' 59 

Total^ 400 

Posture: 

Weight  on  right  foot 48 

Weight  on  left  foot 48 

—  96 

Carries  books  or  baby  on  right  arm 38 

Carries  books  or  baby  on  left  arm 36 

—  74 

Sits  at  desk  or  work  in  faulty  attitude 57 

Carries  heavy  load  on  one  shoulder 2 

Excessive  use  of  right  arm  in  occupation 3 

Total 232 

The  sitting  posture  is  not  the  only  one  in  which  improper  atti- 
tudes may  be  persistently  assumed,  for  even  posture  during  sleep 
may  influence  the  inclination  of  the  body  during  the  hours  of  activity. 
But  the  sitting  position  is  the  one  in  which  the  muscular  support 
is  most  likely  to  be  relaxed,  and  in  which  a  tendency  toward  lateral 
inclination  is  most  likely  to  be  acquired,  since  children  do  not 
often  retain  one  attitude  in  the  erect  position  for  any  length  of  time. 
Bradford  and  Lovett  record  an  observation  of  the  attitudes  of  sixty- 
seven  healthy  adults  undergoing  a  written  examination.  At  the 
end  of  the  second  hour  a  lateral  inclination  of  the  body  was  evident 
in  all,  and  in  three-fourths  of  the  number  to  the  right.  In  about 
this  proportion  of  the  cases  of  lateral  curvature  the  type  of  fixed 
deformity  is  to  the  left  in  the  lumbar  and  to  the  right  in  the  dorsal 
region.  Assuming  that  the  distortion  is  caused  or  influenced  by  the 
habitual  attitude  during  school  hours,  it  would  appear  that  the 
primary  deformity  should  be  more  often  of  the  lumbar  region,  for 
in  the  sitting  posture  the  lumbar  lordosis  is  lessened  or  lost;  thus 
the  bodies  of  the  vertebrae  in  the  lumbar  region  are  subjected  to 
greater  pressure  than  in  the  dorsal  region — a  pressure  which  might 
induce  the  accommodative  changes  in  the  bones  that  accompany 
persistent  deformity. 

The  possibility  of  distinguishing  the  varieties  of  lateral  curva- 
ture in  which  the  primary  distortion  is  lumbar  from  those  in  which 
it  is  dorsal,  by  the  flattening  of  the  dorsal  kyphosis  in  the  former, 
and  its  exaggeration  in  the  latter  instance,  has  been  mentioned. 


168  LATERAL   CURVATURE  OF   THE  SPINE 

Varieties  of  Deformity. — According  to  statistics  from  various 
sources,  about  three-fourths  of  the  well-developed  double  curves 
of  the  spine  are  convex  to  the  right  in  the  dorsal  and  to  the  left  in 
the  lumbar  region,  and,  as  the  distortion  of  the  thorax  is  more 
noticeable  of  the  two,  it  usually  classifies  the  deformity  as  right  or 
left.  The  dorsal  curvature  may  be  either  primary  or  secondary, 
and  the  relative  frequency  of  the  original  deformity,  whether  lum- 
bar or  dorsal,  is  in  doubt,  with  the  probability  in  favor  of  the  former. 

Summary  of  varieties  of  deformity  of  the  spine  under  treatment, 
tabulated  by  Dr.  Truslow: 

1.  Simple  anteroposterior  deformities: 

(o)   Kyphosis 10 

Kypholordosis 1 

Lordosis ■ 1 

—  12 
Round  shoulders: 

(b)   Abducted  scapulae 7  • 

Elevated  scapulae 2 

—  9 

2.  Anteroposterior  abnormalities  most  marked,  but  accompanied  by 

lateral  deviation: 

(a)  With  single  lateral  curve 14 

(b)  With  double  lateral  curves 16 

(c)  With  triple  lateral  curves 7 

—  37 

3.  Rotation  more  marked  than  lateral  deviation: 

(a)   With  double  lateral  curves 22 

(6)   With  triple  lateral  curves 8 

—  30 

4.  Lateral  deviation  more  marked  than  rotation;  direction  of  the 

curves : 
Right  dorsal,  left  lumbar  type: 

(a)   Single  lateral  ciu-ve 22 

(6)    Double  lateral  curves 17 

(c)    Triple  lateral  curves 6 

—  45 
Left  dorsal,  right  lumbar  type: 

(a)   Single  lateral  curve 3 

(6)    Double  lateral  curves 8 

(c)    Triple  lateral  curves 3 

—  14 

Total 147 

It  will  be  noted  that  in  21  cases  anteroposterior  deformity 
was  present  without  lateral  deviation,  and  that  in  37  instances  it 
was  accompanied  by  lateral  deviation.  In  the  remaining  144  cases 
rotation  was  more  marked  than  lateral  devition  in  30  cases,  and 
lateral  deviation  more  marked  than  rotation  in  113.  In  the  entire 
number  of  cases  in  which  lateral  deviation  was  present  it  was  single 
in  39  cases,  double  in  117  cases,  triple  in  24  cases. 

In  890  cases  of  lateral  curvature  tabulated  by  Schulthess  the 
deformity  was  as  follows:^ 

1  Ztschr.  f.  orthop.  Cliir.,  1902,  Bd.  x. 


SYMPTOMS  169 

Total  scoliosis  (single  curve  affecting  the  entire  spine)      173  23  196 

Lumbar  scoliosis  (single  curve  limited  to  the  lumbar 

region) 63  34  97 

Lumbodorsal  scoliosis  (single  curve  limited  to  lumbo- 

dorsal  region) 184  164         348 

Complicated  scoliosis: 

(a)   Right  dorsal,  left  lumbar         191 

lb)    Left  dorsal,  right  lumbar 58  ...  249 

478         412         890 

It  will  be  noted  that  a  very  large  proportion  of  these  cases  were 
in  the  early  stage  of  deformity,  as  indicated  by  the  absence  of  com- 
pensatory curves ;  that  in  80  per  cent,  of  the  293  cases  in  which  the 
curve  was  general  or  most  marked  in  the  lumbar  region,  the  incli- 
nation was  to  the  left;  and  of  the  complicated  or  more  fully  devel- 
oped cases  in  which  the  curve  was  double,  73  per  cent,  were  of  the 
right  dorsal,  left  lumbar  type. 

Symptoms. — In  the  majority  of  cases  the  first  symptom  is  the 
deformity.  This  is  often  discovered  by  the  dressmaker  at  the  age 
when  the  clothing  is  made  to  fit  the  figure  more  closely.  In  certain 
instances  the  deformity  may  be  preceded  or  accompanied  by  pain. 
This  was  present  to  a  greater  or  less  degree  in  about  one-quarter  of 
the  cases  examined  by  Truslow,  and  440  of  Roth's  1000  cases;  slight 
in  134,  moderate  in  163,  severe  in  143.  Pain  may  be  simply  the 
discomfort  or  the  "dragging"  sensation  of  fatigue,  usually  referred 
to  the  lumbar  region,  or  it  may  be  severe  and  neuralgic  in  type. 
The  latter  variety  is  more  common  in  the  cases  in  which  the  deform- 
ity is  extreme.  It  is  said  to  be  the  result  of  pressure  on  nerves,  but 
this  cause  is  exceptional  in  ordinary  cases,  as  it  is  as  often  referred 
to  the  convex  as  to  the  concave  side.  When  the  deformity  is 
extreme — for  example,  when  the  ribs  and  the  iliac  crest  are  in  con- 
tact— direct  pressure  may  explain  the  local  discomfort  referred  to 
this  region.  There  are  also  more  general  symptoms  of  a  neuras- 
thenic or  hysteric  character  that  may  be  due  in  part  to  the  deform- 
ity and  in  part  to  the  debility  of  which  it  may  be  a  result  or  accom- 
paniment. For  it  must  be  borne  in  mind  that  lateral  curvature 
is  one  of  the  postural  deformities  whose  development  is  favored 
by  general  weakness,  as  illustrated  by  the  fact  that  it  is  often 
accompanied  by  other  deformities  of  similar  nature,  particularly 
by  the  weak  foot.  Deformities  of  this  class  that  are  induced  by 
weakness,  in  their  turn  tend  to  prolong  and  to  aggravate  it  by 
hampering  normal  development  and  normal  function. 

In  many  instances  symptoms  of  weakness  and  awkwardness 
precede  the  deformity.  Truslow  states  that  in  a  large  propor- 
tion of  the  cases  investigated  the  patients  had  been  distinctly 
less  active  than  their  companions,  that  they  did  not  enjoy  exer- 
cise, and  were  inclined  to  lead  sedentary  lives.     Teschner^   has 

1  Med.  Rec,  December  16,  1893.- 


170  LATERAL   CVRYATVRE  OF   THE  SPIXE 

called  attention  to  the  same  peculiarity.  He  states  that  the  patients 
are  often  indifferent,  apathetic,  and  lazy.  He  has  noted  also  a 
peculiar  lack  of  coordination  and  muscular  control  as  a  common 
accompaniment  of  the  deformity.  These  s^^nptoms  apply  particu- 
larly to  adolescence,  the  period  of  rapid  gro-u-th  and  instability, 
■when  any  latent  deformity  or  weakness  is  likely  to  be  exaggerated. 
In  younger  subjects  such  symptoms  are  far  less  marked  or  are  absent. 
In  the  cases  in  which  the  deformity  is  extreme,  symptoms  due  to 
interference  with  the  respiratory  and  circulatory  apparatus,  or  to 
displacement  of  the  abdominal  organs,  may  be  present.  Such 
symptoms  are,  however,  rather  unusual  in  cases  of  the  ordinary 
type. 

Diagnosis. — Posture. — When  the  patient  stands  with  the  back 
and  hips  bare,  the  lateral  inclination  of  the  body  and  a  corre- 
sponding asymmetry  of  the  trunk  are  usually  apparent,  even  in 
the  earliest  stage  of  the  aft'ection.  For,  as  has  been  stated,  the 
habitual  assumption  of  the  deforming  attitude  precedes  fixed 
changes  in  and  about  the  spine,  and  this  attitude  will  appear 
when  the  patient  is  asked  to  stand  for  inspection.  If  the  incli- 
nation of  the  body  is  toward  the  left  (Fig.  99),  the  left  arm  will 
hang  in  close  apposition  to  its  lateral  border,  while  on  the  right 
side  an  interval  will  appear  between  the  arm  and  the  trunk.  If 
there  is  a  slight  lumbar  curve  to  the  left  (Fig.  101),  the  right  iliac 
crest  will  be  accentuated.  The  curvature  in  the  dorsal  region  raises 
one  shoulder  (Fig.  106),  the  scapula  on  the  aft'ected  side  projects, 
and  the  distance  between  its  posterior  border  and  the  median  line 
is  increased.  Rotation  of  the  spine  is  sho^Ti  by  the  fulness  or  pro- 
jection of  one  side  accompanied  by  a  corresponding  flatness  or  con- 
cavity on  the  other.  This  is  more  noticeable  when  the  patient 
bends  the  body  forward  so  that  the  horizontal  plane  of  the  back  is 
brought  into  view  (Fig.  100).  Corresponding  changes,  though  of  a 
less  marked  degree,  appear  on  the  anterior  surface  of  the  body; 
for  example,  the  apparent  diminution  in  the  size  of  the  mamma  on 
the  side  of  the  convexity  and  its  relative  depression  or  elevation 
may  attract  attention. 

It  is  probable  that  a  change  in  the  anteroposterior  contour  of 
the  spine  precedes,  in  many  instances  the  lateral  deviation.  Thus 
a  general  droop  of  the  body  associated  with  round  shoulders  and  a 
flattened  chest  may  be  regarded  as  a  predisposing  cause. 

Mobility. — Habitual  posture  implies  disuse  of  certain  attitudes 
and  motions;  thus  limitation  of  the  normal  flexibility  of  the  spine 
is  one  of  the  earliest  signs  of  progressive  deformity.  The  test  of 
the  motion  of  the  dift'erent  regions  of  the  spine  is  therefore  an 
essential  part  of  the  examination.  To  test  the  motion  in  the  lum- 
bar region,  one  fixes  the  pelvis  with  the  hands  while  the  patient 
sways  the  body  in  the  four  directions  and  rotates  it  from  side  to 
side.     It  is  suggested  by  Bradford  and  Lovett  that  direct  lateral 


DIAGNOSIS 


171 


flexibility  may  be  tested  by  placing  blocks  of  wood  under  one  foot 
until  the  limit  of  lateral  flexion  is  reached,  as  shown  by  the  inability 
of  the  patient  to  hold  the  elevated  limb  in  the  extended  position. 
The  experiment  is  then  repeated  on  the  opposite  side.  The  flexi- 
bility of  the  upper  part  of  the  trunk  may  be  tested  by  fixing  the  part 
below  with  the  hands  while  the  patient  flexes,  extends,  and  rotates 
the  body.  It  is  important,  also,  to  test  the  range  of  motion  at  the 
shoulder-joints.  The  normal  individual  should  be  able  to  hold 
the  arms  extended  directly  above  the  head  without  increasing  the 
lumbar  lordosis.  In  many  in- 
stances, however,  it  will  be 
found  that  there  is  a  marked 
restriction  of  this  motion;  in 
fact,  such  restriction  is  almost 
always  an  accompaniment  of 
so-called  round  shoulders. 

The  height  and  weight,  the 
circumference  and  the  expan- 
sion of  the  chest  should  be  re- 
corded, and  a  test  of  the  mus- 
cular strength,  not  only  of  the 
muscles  of  the  trunk,  but  of 
the  members  as  well,  is  of  ad- 
vantage as  throwing  light  on 
the  etiology  and  indicating  the 
general  line  of  treatment. 

Record. — The  most  reliable 
of  the  graphic  records  to  be 
used  in  connection  with  the 
history  are  photographs.  The 
patient  may  stand  behind  a 
thread  screen  (Fig.  122)  in  the 
habitual  attitude.  The  spinous 
processes,  the  iliac  crests,  and 
the  angles  of  the  scapulae  having 
been  marked,  the  exact  amount 
of  Jaterardeviation  of  the  trunk 
will  be  sho^Ti.      The  rotation 

may  be  indicated  also  by  photographing  the  patient  in  the  recum- 
bent posture. 

The  rotation  of  the  spine  is  the  most  important  indication  of 
deformity.  This  may  be  recorded  with  sufficient  accuracy  by 
taking  direct  tracings  of  the  trunk  at  fixed  points  by  means  of  a 
lead  or  zinc  tape  while  the  patient  lies  in  the  recumbent  posture. 

At  the  Hospital  for  Ruptured  and  Crippled  the  shadow  of  the 
trunk  cast  by  an  electric  light  at  a  fixed  distance  is  traced  upon 
a  large  sheet  of  paper.     Upon  this  outline  the  position  of  the  more 


Fig.   122. — The  thread  screen.     From  the 
Boston  Children's  Hospital  Report. 


172  LATERAL  CURVATURE  OF   THE  SPJNE 

important  landmarks  is  indicated.  The  degree  of  rotation  is  shown 
by  transverse  tracings  and  the  hne  of  the  spinous  processes  is  ascer- 
tained by  applying  a  broad  strip  of  adhesive  plaster  to  the  back 
upon  which  the  tip  of  each  spinous  process  is  marked.  The 
anteroposterior  outline  of  the  spine  should  be  recorded,  also  the 
general  attitude  and  the  presence  or  absence  of  other  evidences  of 
weakness  such  as  knock-knees  and  weak  feet. 

Prognosis. — In  the  development  of  lateral  curvature  there  is 
doubtless  a  preliminary  or  predisposing  stage — a  stage  of  progression 
and  a  stage  of  arrest.  All  deformities  of  this  class  are  more  likely 
to  progress  during  the  growing  period.  They  are  likely  to  become 
stationary  when  the  period  of  growth  is  completed.  Thus,  the 
prognosis  is  worse  when  the  deformity  begins  at  an  early  age  than 
when  it  first  appears  in  adolescence.  The  rnost  extreme  and  intract- 
able of  the  simple  cases  are  the  result  of  rhachitis,  in  which  the  de- 
formity appearing  in  infancy  or  early  childhood  has  increased  with 
the  growth  of  the  child. 

If  the  causes  of  deformity  are  such  that  they  operate  to  check 
the  equal  development  of  the  affected  part,  the  prognosis  is  even 
more  directly  influenced  by  the  age  of  the  patient.  For  example, 
empyema,  even  if  the  lung  is  irreparably  damaged,  does  not  cause 
appreciable  deformity  in  the  adult,  but  in  childhood  the  functional 
activity  and  the  growth  of  the  side  of  the  thorax  are  checked  in 
addition  to  the  direct  effect  of  the  adhesions  and  contractions  due 
to  the  disease;  thus  the  deformity  is  likely  to  be  progressive  in 
spite  of  the  treatment.  The  same  is  true  of  paralytic  deformity. 
In  the  ordinary  type  of  lateral  curvature  in  the  adolescent  girl  the 
prognosis  is  influenced,  of  course,  by  the  general  condition  of  the 
patient  and  by  the  character  of  the  occupation.  As  far  as  the  local 
deformity  is  concerned,  the  prognosis  as  regards  improvement  or 
cure  depends  in  great  measure  upon  the  fixed  changes  that  have 
taken  place,  and  upon  the  degree  of  voluntary  and  involuntary 
rectification  that  is  possible.  In  some  instances  the  postural  dis- 
tortion may  be  considerable,  yet  the  fixed  deformity  may  be  very 
slight,  while  in  other  instances  the  fixed  rotation  of  the  spine  may 
be  marked,  although  the  lateral  distortion  is  less  noticeable. 

A  single  curve  is  more  amenable  to  treatment  than  is  a  double 
or  triple  distortion,  because  it  indicates  an  earlier  stage  of  deform- 
ity and  because  the  treatment  may  be  more  effective  when  applied 
to  one  deformity  than  to  several.  If,  however,  the  single  curve 
is  fixed,  the  appearance  of  a  secondary  or  compensatory  curve  at 
another  part  of  the  spine  is  probable,  in  spite  of  preventive 
treatment. 

In  the  majority  of  cases,  fixed  deformity  of  the  spine  as  indicated 
by  rotation  is  already  present  when  the  patient  is  brought  for  treat- 
ment. This  fixed  deformity  might  be  overcome  doubtless  in  certain 
cases,  and  complete  cure  might  be  obtained  were  all  conditions 


SUMMARY  173 

favorable.  But  in  the  practical  sense  a  cure  means  the  relief  of 
symptoms,  the  checking  of  the  progress  of  deformity,  and  the  resto- 
ration of  the  general  symmetry  of  the  trunk.  Such  a  cure  may  be 
obtained  in  most  instances.  The  deformity  of  the  spine  becomes 
symmetrically  divided  on  either  side  of  the  median  line,  the  changes 
incident  to  maturity,  particularly  the  increased  amount  of  adipose 
tissue,  serve  to  conceal  the  irregularities  of  the  outline,  and  the 
history  of  the  distortion  is  completed. 

In  certain  instances,  particularly  in  the  more  extreme  cases,  the 
deformity  may  increase  in  adult  life  and  even  in  old  age.  In  this 
type  the  symptoms  of  discomfort  and  actual  pain  may  be  trouble- 
some throughout  life,  especially  in  the  overworked  and  debilitated 
class.  The  symptoms  directly  incident  to  the  compression  and  dis- 
tortion of  the  internal  organs  have  been  mentioned. 

The  great  majority  of  cases  that  develop  or  that  are  discovered 
in  adolescence  progress  for  a  time  and  come  to  an  end  on  the  ces- 
sation of  growth,  causing  finally  no  s^nnptoms  other  than  the  loss 
of  symmetry  that  may  be  more  or  less  satisfactorily  concealed  by 
the  art  of  the  dressmaker  and  by  the  corset. 

It  would  appear,  then,  that  lateral  curvature  of  the  spine  is 
always  of  sufficient  gravity  to  merit  treatment  and  supervision 
until  its  cure  or  arrest  is  assured.  If  its  discovery  leads  to  the 
improvement  of  the  general  condition  and  to  the  avoidance  of 
unheal thful  influences  it  may  be  even  of  benefit  to  the  patient. 

Summary. — Lateral  curvature  in  a  young  child  is  of  far  greater 
importance  than  in  an  older  subject  because  of  the  probability  of 
an  increase  of  deformity.  Extreme  deformity  is  always  a  source 
of  weakness  and  usually  of  discomfort  to  the  patient.  Incipient 
deformity  may  be  cured  and  cure  is  not  impossible  even  when 
deformity  is  more  advanced,  but  in  this  more  than  in  any  other 
postural  deformity  absolute  cure  implies  early  diagnosis  and  pre- 
vention rather  than  the  correction  of  fixed  distortion. 

The  progress  of  deformity  of  the  ordinary  type  is  indicated  by : 

1.  The  habitual  assumption  of  an  attitude  simulating  deformity. 

2.  Limitation  of  motion  in  the  directions  opposed  to  the  habitual 
attitudes. 

3.  Fixed  lateral  deviation  of  the  spine  accompanied  by  rotation 
or  twisting  of  the  column. 

One  rarely  has  the  opportunity  to  note  the  development  of 
lateral  curvature,  and  when  patients  are  brought  for  treatment 
fixed  deformity  is  usually  present.  It  is  very  difficult  to  entirely 
overcome  fixed  distortion,  while  it  is  comparatively  easy  to  correct 
simple  postural  deformity  in  which  the  secondary  changes  are  ab- 
sent or  but  slightly  advanced.  On  this  account  it  has  been  cus- 
tomary to  divide  lateral  curvature  into  two  classes — the  true  and 
and  the  false — or  to  speak  of  rotary  lateral  curvature  as  distinct 
from  lateral  curvature.     Thus,  the  term  true  or  rotary  curvature 


174 


LATERAL  CURVATURE  OF   THE  SPINE 


would  be  limited  to  those  cases  in  which  the  changes  are  fixed  and 
in  which  cure  is  practically  impossible,  while  false  or  simple  or  pos- 
tiu-al  lateral  curvature  would  include  the  early  or  curable  class. 
But  as  the  two  forms  are  simply  stages  in  the  same  process  it  would 
seem  preferable  to  speak  of  the  incipient  and  the  later  stages  of 
lateral  curvature,  or  of  reducible  or  irreducible  deformity,  the  dis- 
tinctions that  are  made  in  classifying  distortions  of  similar  origin 
elsewhere. 

This  point  of  view  is  of  advantage  because  it  relieves  the  subject 
of  much  of  the  obscurity  that  has  resulted  from  this  arbitrary 
division.  It  emphasizes  the  fact,  also,  that  the  habitual  assumption 
of  an  improper  attitude  that  simulates  deformity  is  the  first  step 
toward  permanent  distortion,  particularly  in  individuals  w'ho  by 
inheritance  or  by  constitutional  tendency  or  by  occupation  are 
predisposed  to  it. 


Fig.  123. — Adjustable  school  desks  and  seats.      Scheiber  and  Klein.      (Redard.) 

Prevention  of  Deformity. — Prevention  includes  the  avoidance 
of  all  the  predisposing  or  exciting  causes  of  weakness  as  well  as 
of  deformity.     These  it  is  hardly  necessary  to  enumerate. 

The  first  and  most  important  preventive  measure  is  the  dis- 
covery of  deformity  or  the  tendency  to^deformity  at  a  time  when 
it  may  be  checked  or  cured.  To  discover  deformity  at  this  period 
of  its  development  one  must  look  for  it,  thus  the  regular  inspection 
of  the  naked  bodies  of  the  children  under  his  care  should  become  a 
routine  practice  of  the  family  physicain.  Deformity  in  this  sense 
includes  not  only  fixed  distortions,  but  improper  attitudes  and  pos- 
tures of  every  variety  as  well. 

The  importance  of  the  attitude  which  is  habitually  assumed 
during  occupation  has  been  mentioned.  Therefore  the  provision 
of  proper  desks  and  seats  for  school-children  is  a  very  essential  part 
of  preventive  treatment. 


TREATMENT 


175 


The  seat  of  the  chair  should  be  deep  enough  to  support  the  thighs, 
yet  it  should  not  interfere  with  flexion  at  the  knees.  It  should  be 
of  such  height  as  to  allow  the  feet  to  rest  firmly  on  the  floor,  and 
it  should  be  inclined  slightly  backward.  The  back  of  the  chair 
should  extend  to  about  the  level  of  the  shoulders;  it  should  be  in- 
clined slightly  backward,  but  arched  somewhat  forward  in  the 
lumbar  region  in  order  to  conform  to  the  normal  lordosis  when  the 
child  sits  in  the  erect  posture.  The  desk  should  be  as  close  to  the 
body  as  is  possible,  so  that  the  child  need  not  lean  forward  when 
reading  or  writing.  The  height  of  the  desk  should  be  slightly  less 
than  the  level  of  the  elbows  when  the  child  sits  erect,  and  the  inclina- 


mmm 


Fig.  124. — Adjustable  school  seat.     (Miller  and  Stone.) 


tion  should  be  sufficient  to  hold  the  book  at  the  proper  distance  from 
the  eyes  (Figs.  123  and  124).  The  vertical  handwriting  is  of  advan- 
tage in  that  the  children  are  taught  to  face  the  desk  squarely,  as 
contrasted  with  the  lateral  twist  of  the  body,  the  usual  attitude  for 
writing. 

Treatment. — The  treatment  of  rotary  lateral  curvature  of  the 
spine  does  not  differ  in  character  from  the  treatment  of  any  other 
weakness  or  deformity,  but  as  the  application  of  the  treatment  is 
difficult  the  results  are  far  from  definite  and  satisfactory.  This 
explains,  doubtless,  the  apparently  opposing  theories  and  methods 
of  treatment  that  are  still  advocated. 


176  LATERAL   CURVATURE  OF   THE  SPINE 

Principles  of  Treatment. — The  principles  of  the  treatment  of  any 
form  of  weakness  not  directly  induced  by  disease  may  be  summarized 
as  follows: 

1.  To  correct  deformity. 

2.  To  overcome  all  restriction  to  passive  motion. 

3.  To  strengthen  the  weakened  muscles,  especially  those  whose 
action  is  opposed  to  habitual  deformity. 

4.  To  prevent  as  far  as  may  be  overfatigue  and  predisposing 
postures. 

5.  To  support  the  weak  part  by  a  brace  if  deformity  cannot  be 
prevented  otherwise. 

In  applying  these  principles  to  the  treatment  of  the  distorted 
spine,  the  removal  of  restriction  to  passive  motion  in  all  directions, 
is  difficult  because  of  the  variety  of  muscles  and  other  tissues  that 
may  have  become  involved,  and  because  the  bodies  of  the  vertebrae 
lying  within  the  trunk,  of  which  the  distortion  is  always  greater 
than  of  the  spinous  processes,  can  be  only  indirectly  affected  by 
voluntary  or  by  passive  movements. 

The  cultivation  of  the  muscular  system,  and  particularly  of 
those  muscles  whose  action  is  opposed  to  the  habitual  deformity, 
as  applied  to  the  trunk,  is  difficult,  because  there  are  in  nearly 
all  developed  cases  two  curves,  the  one  primary  and  the  other 
secondary,  in  direction  directly  opposed  to  one  another.  These 
opposing  curves  are  supplied  in  great  part  by  the  same  muscles, 
and  it  is  difficult  by  voluntary  effort  to  lessen  the  convexity  of 
one  without  at  the  same  time  increasing  that  of  the  other. 

The  avoidance  of  predisposing  attitudes  and  fatigue  is  especially 
difficult  because  the  restful  sitting  posture  is  that  which  predisposes 
deformity.  Thus,  only  in  recumbency  is  the  spine  entirely  relieved 
from  weight,  and  even  at  such  times  the  deformity  may  be  favored 
by  the  habitual  attitude  of  the  patient. 

Finally,  the  spine  cannot  be  supported  without  at  the  same  time 
restraining  its  normal  motion.  Nor  is  any  brace  perfectly  efficient, 
for  while  it  may  prevent  the  lateral  deviation  it  can  exercise  little 
direct  action  on  the  rotation  of  the  spinal  column. 

It  is  apparent  then  that  it  is  not  the  difficulty  of  formulating 
principles,  but  the  difficulty  of  applying  them  that  makes  the  thera- 
peutics of  rotary  lateral  curvature  of  the  spine  perplexing.  In 
practice  one  must  recognize  the  limitations  of  all  systems  of  treat- 
ment as  applied  to  this  particular  deformity,  and  select  and  combine 
methods  that  may  be  most  applicable  to  the  particular  case  under 
treatment. 

For  example,  in  the  treatment  of  rhachitic  scoliosis  in  a  young 
child  one  cannot  count  upon  the  voluntary  assistance  of  the  patient; 
therefore  treatment  by  simple  g\aTinastic  exercises  is  impracti- 
cable. In  this  class  of  cases  forcible  correction  of  the  deformity 
and  retention  by  a  support  combined  with  massage  and  methodical 


TREATMENT  111 

manual  correction  and  even  the  removal  of  superincumbent  weight 
by  recumbency  on  the  stretcher  frame  would  be  treatment  of 
selection.  By  such  means  one  may  hope  at  this  period  of  rapid 
growth  to  induce  a  transformation  of  the  deformed  vertebral  bodies 
to  an  approximation  at  least  of  the  normal.  The  correction  of 
deformity,  which  must  almost  inevitably  increase  with  the  growth 
of  the  patient  would  quite  outweigh  the  disadvantage  of  depriving 
the  muscles  of  their  normal  stimulus  during  the  corrective  period 
of  treatment. 

In  the  ordinary  type  of  mild  deformity  in  older  subjects  one 
would  expect  to  attain  the  best  practical  results  by  gymnastic 
training  an^  by  regulation  of  the  postures.  Although  even  in  this 
class  the  primary  correction  of  deformity  by  force  and  fixation  offers 
the  best  opportunity  for  success. 

The  advisability  of  a  change  of  occupation  has  been  mentioned. 
It  is  probable  that  if  the  patient  with  incipient  or  even  more  pro- 
nounced curvature  of  the  spine  were  removed  from  school,  were 
transferred  to  the  country  where  during  the  succeeding  years  of 
childhood  and  adolescence  much  of  the  time  might  be  passed  in 
active  exercise  in  the  open  air,  the  final  result  would  compare  very 
favorably  with  that  attained  by  active  treatment  under  less  favor- 
able circumstances.  Such  complete  change  of  occupation  and  sur- 
roundings is,  of  course,  impracticable  in  most  instances.  Lateral 
curvature  of  the  spine  is  not  a  serious  disease,  it  is  simply  an  insidi- 
ous distortion  which  rarely  causes  more  than  comparatively  slight 
discomfort.  It  is  usually  overlooked  in  the  incipient  stage  when  it 
might  be  checked  or  cured,  and  when  the  deformity  finally  attracts 
attention  it  is  often  no  longer  amenable  to  correction.  Under  these 
circumstances,  with  the  uncertainty  that  exists  as  to  the  ultimate 
prognosis,  the  tediousness  of  treatment  which  cannot  offer  the 
assurance  of  definite  cure,  it  is  readily  apparent  why  the  affection 
is  not  one  for  the  treatment  of  which  any  great  sacrifice  is  con- 
sidered essential. 

A  third  class  of  cases  would  include  the  fixed  deformity  in  older 
subjects,  many  of  whom  are  obliged  to  assume  in  their  occupations 
attitudes  that  predispose  to  deformity.  In  the  treament  of  this 
class  a  support  to  relieve  discomfort  and  to  prevent  exaggerated 
distortion  may  be  essential. 

Thus  there  are  four  classes  or  types  of  scoliosis  in  which  distinct 
methods  of  treatment  may  l?e  employed. 

1.  Curvatures  in  very  young  children,  in  which  correction 
and  fixation  are  indicated  in  the  hope  of  inducing  a  transformation 
of  the  bones  and  other  tissues  by  natural  outgrowth. 

2.  The  milder  degrees  of  deformity  for  which  treatment  by  exer- 
cises and  by  favoring  postures  is  that  of  selection,  and  in  which 
support  is  a  temporary  and  incidental  adjunct,  the  class  also  in 
which  forcible  methodic  correction  offers  a  prospect  of  cure. 

12 


178  LATERAL  CURVATURE  OF   THE  SPINE 

3.  The  more  advanced  cases  in  which  support  should  be  com- 
bined with  corrective  exercises. 

4.  Fixed  deformity  in  older  subjects,  and  those  cases  caused  by 
disease;  as,  for  example,  by  paralysis,  by  empyema  and  the  like,  for 
which  constant  support  may  be  required. 

As  a  rule,  however,  no  absolute  therapeutic  distinction  can  be 
made,  and  treatment  by  exercises  and  postures  should  be  employed 
whenever  practicable  in  all  cases,  whether  supports  are  used  or  not. 

Posture  and  Exercises. — Whatever  may  have  been  the  original 
cause  of  the  distortion  of  the  spine  and  whatever  may  be  its  degree, 
it  is  more  marked  when  the  patient  is  fatigued.  Fatigue  in  the 
normal  individual  is  shown  by  an  increase  of  the  normal  antero- 
posterior curves;  fatigue  in  the  deformed  subject  causes  an  increase 
in  the  pathological  curves.  It  requires  far  more  muscular  effort 
to  hold  the  deformed  spine  in  the  best  possible  attitude  than  to  hold 
the  normal  spine  in  the  correct  posture.  ^Motion  in  the  normal 
spine  is  as  free  in  one  direction  as  in  another,  and  it  simply  requires 
a  proper  balancing  of  the  muscular  force  to  hold  it  in  the  median 
line.  But  when  there  is  a  fixed  deformity,  to  overcome  which,  even 
in  part,  requires  the  conscious  effort  of  the  patient,  it  is  evident  that 
on  the  relaxation  of  this  effort  the  spine  will  sink  back  into  the  hab- 
itual posture.  The  more  confirmed  the  deformity  the  greater  must 
be  the  eft'ort  to  overcome  it,  and  the  more  rapidly  will  fatigue  be 
manifest.  Fatigue,  or,  rather,  the  relaxation  of  conscious  mus- 
cular eft'ort,  is  favored  by  attitudes  that  do  not  require  the  balanc- 
ing action  of  the  muscles.  For  example,  the  sitting  posture  during 
school  hours  favors  deformity,  while  the  constant  alternation  of 
postures  in  work  or  play  that  requires  muscular  activity  opposes 
it.  Thus  the  selection  of  occupations,  or,  at  least,  the  restriction 
of  the  time  passed  in  inactive  postures,  is  an  important  part  of 
treatment. 

As  improper  attitudes  are  favored  by  weakness  of  muscles, 
and  as  the  maintenance  of  the  best  possible  position  requires  a 
greater  expenditure  of  muscular  force  than  is  required  in  the  normal 
individual,  the  strengthening  of  all  the  muscles  of  the  body,  and 
particularly  of  those  of  the  back,  by  gymnastic  exercises,  even 
beyond  the  normal  standard,  is  the  most  important  indication  in 
treatment. 

One  of  the  most  eft'ective  systems  of  treatment  by  gymnastics 
is  that  advocated  by  Teschner,  of  Xew  York.  On  the  theory 
that  lateral  curvature  is  induced  by  or  that  its  development  is 
favored  by  a  general  lack  of  muscular  strength  and  lack  of  mus- 
cular control  and  coordination,  Teschner  urges  the  necessity  of 
the  systematic  cultivation  of  all  the  muscles  of  the  body  as  well 
as  those  of  the  trunk,  the  part  particularly  at  fault.  He  also 
insists  upon  the  importance  of  exercising  each  muscular  group  to 
the  point  of  fatigue  on  the  theory  that  a  muscle  cannot  be  developed 


TREATMENT  179 

to  its  full  capacity  unless  it  is  thoroughly  fatigued  by  uninterrupted 
automatic  contractions  and  relaxations.  The  term  automatic 
implies  that  the  patient  shall  be  so  thoroughly  trained  in  the 
rhythmical  movements  that  they  require  no  thought  for  their  per- 
formance. Thus,  ease  and  grace  may  replace  awkwardness  and 
incoordination. 

The  system  is  modified  from  one  taught  by  Attilla,  a  "trainer 
of  strong  men."  It  consists  of  a  series  of  exercises  with  light  dumb- 
bells, and  it  is  supplemented  by  so-called  heavy  work.  The  exer- 
cises are  designed  for  systematic  cultivation  of  all  the  muscles  of 
the  body,  the  heavy  work  more  directly  for  the  correction  of  the 
deformity  of  the  spine. 

General  Exercises. — ^The  exercises  should  be  performed  before 
a  mirror,  the  patient  being  clad  in  a  close-fitting  rowing  suit,  so 
that  the  attitudes  may  be  constantly  observed  by  the  patient  and 
by  the  instructor.  The  greatest  attention  is  paid  to  the  perfection 
of  the  alternating  movements  of  the  limbs  in  order  that  they  may 
become  in  time  purely  automatic  in  character.  During  the  per- 
formance of  the  exercises  the  patient  holds  himself  in  the  best 
possible  position. 

These  exercises  were  described  and  illustrated  by  Teschner  in 
the  Annals  of  Surgery  for  August,  1895,  from  which  they  are,  with 
his  permission,  reproduced. 

"A  pair  of  dumb-bells,  weighing  from  one-half  to  five  pounds 
each,  according  to  the  ability  of  the  patient,  is  used  in  a  series 
of  twenty-six  exercises. 

"The  Exercises. — The  patient  stands  erect,  the  heels  together, 
the  toes  apart,  the  knees  thoroughly  extended,  the  abdomen  re- 
tracted, the  chest  high,  the  head  well  poised,  and  the  patient  look- 
ing intently  and  sharply  into  his  or  her  own  eyes  in  the  mirror, 
the  lips  being  evenly,  but  not  too  firmly  closed,  and  the  facial 
muscles  in  repose.  The  patient  should  breathe  easily  and  regularly 
while  exercising  (Figs.  125  and  126). 

"1,  The  upper  extremities  are  fully  extended  downward,  the 
forearms  supinated,  the  elbows  remaining  close  to  the  sides  of  the 
body,  and  the  upper  arms  being  fixed ;  the  forearms  are  alternately 
and  automatically  fully  flexed  and  extended,  the  wrists  and  entire 
body  being  fixed  and  immovable.    Twenty  to  fifty  times  (Fig.  127). 

"2.  The  same  position  and  exercise,  except  that  the  forearms 
are  fully  pronated,  and  remain  so  during  alternate  flexion  and 
extension.     Twenty  to  fifty  times  (Fig.  128). 

"3.  Both  bells  over  the  shoulders,  the  arms  abducted  at  right 
angles  to  the  body  and  in  the  same  vertical  and  horizontal  planes, 
the  forearms  fully  flexed  upon  the  arms,  and  the  wrists  fully  flexed 
upon  the  forearms.  The  forearms  and  wrists  are  then  alternately 
and  automatically  extended  and  flexed.  Ten  to  twenty  times 
(Fig.  129). 


180 


LATERAL  CURVATURE  OF   THE  SPINE 


"4.  The  same  position  and  exercises,  except  that  both  upper 
extremities  are  flexed  and  extended  at  the  same  time.  Five  to 
fifteen  times  (Fig.  130). 


Fig.  125 


Fig.  126 


Fig.  128 


Fig.  129 


"5.  Both  upper  extremities  fully  extended  forward  on  a  level 
with  the  shoulders,  the  dorsum  of  the  hands  outward.  They 
are  then  fully  and  forcibly  abducted  on  a  horizontal  plane,  the 


TREATMENT 


181 


patient  at  the  same  time  raising  the  body  upon  the  toes,  and  are 
then  permitted  to  recede  to  the  original  position,  the  body  rest- 


FiG.   130 


Fig.  132 


Fig.  131 


Fig.  133 


ing  on  the  toes  and  heels,  the  elbows  and  wrists  still  rigid,  the 
bells  not  being  permitted  to  touch  as  they  approximate  each  other. 
Five  to  ten  times  (Fig.  132). 


182 


LATERAL  CURVATURE  OF   THE  SPINE 


"6.  Bells  in  the  position  of  exercises  Xo.  3  and  No.  4.  The 
arms  are  fully  extended  alternately  above  the  head.  Ten  to 
twenty  times  (Fig.  133). 


Fig.   136 


Fig.  137 


"7.  Bells  in  front  of  the  thighs,  forearms  pronated,  and  bells 
alternately  raised  to  the  level  of  the  shoulders,  the  elbows  and 
wrists  being  fixed.     Ten  to  twenty  times  (Fig.  134). 


TREATMENT 


1S3 


''8.  The  arms  abducted  at  right  angles  to  the  body,  the  bells 
rotated  rapidly  and  forcibly  forward  and  backward,  the  elbows 
being  fixed.     Five  to  ten  times  (Fig.  135). 


Fig.  138 


Fig.  139 


Fig.  140 


'■■)#^^%1i 


Fig.  141 


Fig.  142 


184 


LATERAL  CURVATURE  OF   THE  SPINE 


"9.  The  arms  abducted  at  right  angles  to  the  body,  the  thumbs 
upon  one  ball  of  each  bell,  the  hands  circumducted  forward  from 
above  downward,  the  ball  upon  which  the  thumbs  rest  describing 
circles,  the  elbows  and  shoulders  being  fixed.  Five  to  ten  times 
(Fig.  135). 

"  10.  The  same  as  No.  9,  the  hands  being  circumducted  backward. 
Five  to  ten  times  (Fig.  136). 

"11.  The  bells  to  the  side.  Right  face  upon  left  heel,  then  plac- 
ing the  foot  at  right  angles  to  right  foot  opposite  the  arch,  the 
knees  slightly  flexed,  the  right  hand  at  waist  line  against  the  body, 
the  bell  being  perpendicular.  Second  part  of  motion:  strike  from 
the  shoulder  to  level  of  the  face,  advancing  a  step  upon  the  left  foot, 
rapidly  extending  the  right  thigh  and  leg,  the  right  foot  being  fixed 
upon  the  floor,  and  quickly  back  to  position.  Ten  to  fifteen  times 
(Figs.  137  and  138). 


Fig.  143 


Fig.   144 


"12.  Exactly  the  reverse  of  No.  11.     Ten  to  fifteen  times. 

"13.  Bells  extended  above  the  head,  palmar  surfaces  looking 
forward,  bending  do\^^l  to  the  floor,  the  knees  remaining  extended, 
and  return.     Five  to  fifteen  times  (Figs.  139  and  140). 

"14.  Bells  downward  at  the  sides,  raising  and  dropping  the 
shoulders.     Ten  to  twenty  times  (Fig.  141). 

"  15.  Bells  downward  at  the  sides,  flexing  the  spine  laterally, 
first  to  the  right  and  then  to  the  left.  Ten  to  twentv  times  (Fig. 
142). 

"  16.  Both  arms  are  extended  forward  to  about  forty-five  degrees 
and  abducted  at  about  the  same  angle,  then  forcibly  crossed  in 


TREATMENT 


185 


front  of  the  chest,  causing  the  pectoral  muscles  to  contract 
vigorously,  the  elbows  and  wrists  being  fixed,  and  then  back  to 
the  original  position.  Five  to  twenty  times,  alternating  the  right 
and  left  hands  above  (Fig.  143). 


Fig.  145 


Fig.  146 


Fig.  147 


Fig.   148 


"17.  Bells  at  the  sides,  palmar  surfaces  looking  forward.  Ex- 
tend arms  backward  in  a  vertical  plane  as  forcibly  as  possible, 
holding  them  rigid  in  the  fully  extended  position  for  a  few  moments, 


186 


LATERAL  CURVATURE  OF   THE  SPIXE 


and  then  returning  the  bells  to  the  sides.     Five  to  fifteen  times 
(Figs.  144  and  145). 

"  18.  Bells  to  the  sides.     Raise  the  body  upon  the  toes  and  sink 
to  the  original  position.     Ten  to  twenty  times  (Fig.  146). 


Fig.   149 


Fig.  150 


Fig.   151 


Fig.   152 


"19.  Same  position.     Raise  the  toes  as  far  as  possible  from  the 
floor,  the  body  remaining  erect.     Ten  to  twenty  times  (Fig.  147). 


TREATMENT  187 

"20.  Same  position.  The  patient  squats,  abducting  the  knees 
and  resting  upon  the  toes,  the  heels  being  raised,  the  trunk  per- 
fectly erect,  then  resuming  first  position.  Five  to  twenty  times 
(Fig.  148). 

"21.  Same  position.  Standing  upon  left  foot.  Flexing  the 
right  thigh  to  a  right  angle  to  the  body,  extending  the  knee  and 
ankle  fully  The  patient  squats  on  the  left  ham,  the  left  heel 
remaining  on  the  floor,  and  then  resumes  the  first  postiton.  Two 
to  five  times  (Fig.  1^9) . 

"22.  The  same  standing  upon  the  right  foot.  Two  to  five 
times. 

"23.  The  same  position.  Alternately  and  forcibly  flexing 
the  thighs  and  the  legs,  causing  the  knees  to  touch  the  shoulders. 
Ten  to  twenty  times  (Fig.  140). 

"24.  The  same  position  as  in  No.  21,  extending  the  right  lower 
extremity,  the  right  bell  inside  the  thigh,  the  right  foot  moved 
in  a  circle  on  a  horizontal  plane  to  complete  extension  backward, 
and  resuming  the  first  position.  Two  to  five  times  (Figs.  151 
and  152). 


X. 


Fig.  153 

"25.  The  same  as  No.  24,  standing  upon  the  right  foot.  Two 
to  five  times. 

"26.  The  patient  lying  supine  upon  the  floor,  the  lower  ex- 
tremities fully  extended,  the  bells  resting  upon  the  chest,  then 
raising  the  trunk  to  the  sitting  position,  the  lower  extremities 
remaining  extended,  and  the  eyes  being  fixed  upon  the  ceiling, 
and  returning  to  the  original  position,  touching  the  back  of  the 
head  only  on  the  floor;  thus  the  hyperextension  of  the  spine  is 
maintained.     Five  to  twenty  times  (Fig.  153)." 

I  consider  these  floor  exercises  especially  useful,  and,  in  prac- 
tice, add  several  others  to  those  described  by  Teschner,  viz. : 

27.  The  patient  lying  as  in  Fig.  153,  lifts  each  fufly  extended 
leg  alternately  a  distance  of  about  two  feet  from  the  floor,  then 
lets  it  slowly  sink  to  its  original  position.     Ten  times. 

28.  Both  limbs  together.     Five  times. 


188 


LATERAL   CURVATURE  OF   THE  SPINE 


29.  The  patient  lying  extended  in  the  prone  position,  places 
the  palms  of  the  hands  on  the  hips  and  "looks  at  the  ceiling," 
overextends  the  spine  as  much  as  possible,  then  sinks  slowly  to 
the  original  position. 

30.  Each  leg  fully  extended  is  lifted  upward  alternately  as  far 
as  possible  (hyperextension  at  the  hips).     Ten  times. 

31.  Hyperextension  at  both  hips  simultaneously  if  possible. 
Five  times. 


Fig.  154.- 


-Scoliosis  of  an  advanced  type  accompanied  by  dyspnea  and  cyanosis. 
(Teschner.) 


"When  the  patient  has  become  proficient  in  these  exercises, 
they  should  be  done  at  home  every  morning  and  evening. 

"The  Heavy  Work. — Bells,  weighing  from  five  to  eighty 
pounds  each,  and  steel  bars  and  bar-bells,  weighing  from  twenty- 
six  to  over  one  hundred  and  eleven  pounds,  are  used  in  different 
ways.  Bells  are  pushed  from  the  shoulders  above  the  head  alter- 
nately as  often  as  the  patient  is  able  (Figs.  156  and  157). 


TREATMENT 


189 


"  The  patient  is  instructed  to  swing  a  heavy  bell  with  one  hand 
from  the  floor  above  the  head  and  down  again,  the  elbow  and  the 
wrist  being  fixed,  and  the  motion  repeated  as  often  as  possible 
in  a  systematic  manner;  then  with  the  other  hand  the  same  number 
of  times  and  later  with  both.  This  exerts  all  the  extensor  muscles 
from  the  toes  to  the  head  in  rapid  succession." 


V 

f 

1:        :    . 

'^MlMB:' 

1 

B_J 

^l^^n'^' 

1 

■^^^^^m 

\ 

i 

Fig.   155. — The  same  patient  swinging  30-pound  bell,  showing  the  musculardevelop- 

ment.     (Teschner.) 

(For  this  exercise  the  patient  stands  firmly,  with  the  legs  astride 
of  the  heavy  bell,  and  then,  bending  over,  he  seizes  it  and  throws 
the  extended  arm  upward  entirely  by  the  action  of  the  back  muscles. 
The  bell  is  poised  for  a  moment  above  the  head,  and  it  is  then  swung 
downward,  carrying  the  extended  arm  between  and  behind  the 
legs). 

"When  a  heavy  bell  is  pushed  or  swung  above  the  head  on 


190 


LATERAL  CURVATURE  OF   THE  SPINE 


the  side  opposite  the  scoliosis,  the  action  of  the  back  muscles,  to 
sustain  the  weight  and  equilibrium,  is  such  as  to  cause  the  curved 
spine  to  approximate  a  straight  line  (Fig.  157).  A  similar  result 
is  produced  when  a  heavy  weight  is  held  by  the  side  of  the  erect 
body  on  the  scoliotic  side,  the  arm  being  at  full  length. 


Fig.  156. — The  patient  pushing  25- 
pound  bells;  the  right  arm  up. 
(Teschner.) 


Fig.  157. — The  patient  pushing  25- 
pound  bells;  the  left  arm  up. 
(Teschner.) 


"When  a  heavy  bar  is  raised  above  the  head  with  both  hands 
the  patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  main- 
tain an  equilibrium.  This  necessitates  the  bending  of  the  head 
backward,  the  straightening  and  h^'perextending  of  the  spine, 
and  consequently  correcting  a  faulty  position  with  a  weight  super- 
imposed. The  heavier  the  weight  put  above  the  head,  whether 
with  one  hand  or  with  two,  the  more  the  patient  must  exert  him- 
self or  herself  to  attain  and  maintain  a  correct  or  an  improved 


TREATMENT 


191 


attitude  in  order  to  sustain  the  equilibrium.  (By  an  improved 
attitude  I  mean  the  greatest  amount  of  correction  of  the  devia- 
tion of  the  spine  that  the  fixation  of  a  deformity  will  allow) .  Hence 
the  greater  the  weight,  the  more  forcible  the  actions  of  the  muscles 
become,  and  the  greater  the  temporary  reduction  of  a  deformity. 
It  is  by  means  of  frequent  and  forcible  temporary  reductions  of 
deformities,  by  voluntary  muscular  action,  that  we  can  hope  to 
improve,  and  do  improve,  those  cases  which  are  amenable  to  any 
form  of  active' treatment. 

"When  a  patient,  lying  supine  upon  the  floor,  raises  a  heavy 
bar  above  the  head  so  that  the  arms  are  perpendicular  to  the  floor, 
the  weight  of  the  bar,  the  position  and  weight  of  the  body,  and  the 
action  of  the  muscles  tend  to  broaden  the  entire  back  and  shoulders, 
and  a  slow  downward  movement  tends  to  widen  the  entire  chest, 
and  most  markedly  at  the  shoulders.  The  frequent  repetition  of  the 
upward  and  downward  movements  plays  an  important  part  in  the 
rapid  development  of  the  chest  and  back.  Pushing  the  bells  above 
the  head,  swinging  them  with  each  hand  separately  and  with  both 
hands  together,  raising  a  bar  above  the  head,  standing  and  lying 
down,  and  the  exercises  before  enumerated,  constitute  one  day's 
work. 

Record  of  the  Work  Performed  by  a  Girl  Fourteen  Years  of  Age  (Teschner). 


Date, 

Regu- 
lar ex- 
ercises 

Pushing 
two  10-lb. 

Swinging 
with  each 
hand  one 

Swinging 
with  both 
hands  two 

Pushing 
two  20-lb. 

50-lb.  bar  above  the 
head. 

1895.' 

Bells. 

bells. 

15-lb.  bell, 
right  to  left. 

15-lb.  bells. 

bells. 

Standing. 

Lying 
down. 

April    6 

3  lbs. 

"       9 

" 

100 

10-10 

5 

Instructed 

Instructed 

"     11 

150 

Two    15-lb. 

bells 

25-25 

One  20-lb. 

bell 

15 

10 

2 

5 

"     13 

" 

50 

25-25 

25 

12 

5 

10 

"     16 

" 

54 

30-30 

35 

18 

7 

12 

"     18 

60 

35-35 

One  25-lb. 

bell 

40 

Two  20-lb. 

bells 

20 

7 

15 

"     20 

" 

70 

20-20 

20 

30 

10 

15 

"     25 

" 

90 

22-22 

25 

33 

15 

16 

"    27 

" 

100 

35-35 

30 

50 

17 

20 

"     30 

" 

110 

50-50 

35 

60 

20 

22 

May     2 

" 

120 

60-60 

36 

70 

20 

25 

One  30-lb. 

Two  25-lb. 

One  64-lb. 

One  64-lb. 

bell 

bells 

bar 

bar 

"       4 

" 

140 

20-20 

40 

25 

5 

10 

"       7 

" 

150 

25-25 

45 

30 

7 

12 

"     14 

" 

160 

27-27 

50 

34 

9 

13 

"     16 

*' 

170 

30-30 

55 

40 

10 

14 

"As  the  amount  of  work  performed  by  a  patient  depends  upon 
the  last  previous  record  of  that  patient,  that  record  must  be  im- 


192  LATERAL   CURVATURE  OF   THE  SPIXE 

proved  upon  at  each  succeeding  visit,  unless  there  be  a  good  reason 

to  the  contrary.  ]\Iost  patients  can  well  stand  three  treatments 
a  week  (vide  table).  In  mild  habitual  cases  improvement  in  de- 
portment is  noticed  by  the  patient's  relatives  and  friends  and  by 
the  patients  themselves  within  the  first  two  weeks.  In  these  cases 
two  months'  treatment  usually  suffices  to  effect  a  'complete'  cure. 
In  the  more  severe  cases  such  rapid  results  cannot  be  expected,  but 
a  certain  appreciable  improvement  is  effected,  and  the  amount  of 
improvement  depends  upon  the  persistent  continuance  of  the  treat- 
ment. "When  there  is  fixed  rotation  of  long  standing,  with  bony 
and  ligamentous  changes,  the  prospect  is  not  as  good;  but  even  in 
those  cases  considerable  improvement  will  be  evident. 

"Patients  are  not  permitted  to  wear  supports  of  any  kind,  not 
even  corsets.  They  should  not  exercise  until  at  least  two  hours 
after  a  meal,  nor  when  menstruating.  The  general  health  is  im- 
proved by  the  exercises;  the  patients  gain  in  height  and  weight. 
The  girth  and  breadth  measurements,  chest  depth,  strength  tests, 
and  lung  capacity  are  generally  increased,  and  the  depth  of  the 
abdomen  is  usually  decreased.  In  some  cases,  especially  those  of 
undersized  patients,  the  increase  in  height  is  very  rapid,  and  it  is 
certainly  more  than  the  increase  by  ordinary  growth.  There  were 
marked  cases  of  flat-foot  which  were  benefited.  The  flat  feet 
became  shorter  through  the  exercises  by  the  increase  in  depth  of 
the  inner  arches." 

This  system  of  exercises  combines  a  certain  forcible  correction  of 
deformity  and  restoration  of  mobility  by  means  of  the  "heavy 
work"  with  muscle  building.  It  has  the  merit  also  of  making  an 
immediate  mental  impression  upon  the  patient  which  no  other 
system  can  make;  for  if  the  patient  does  not  "strain  every  nerve" 
he  must  certainly  exercise  every  muscle  to  preserve  the  equilibrium 
while  supporting  the  heavy  weights,  and  this  mental  impression  is, 
undoubtedly,  one  of  the  important  elements  in  successful  treatment. 

The  system  has  the  disadvantage,  if  disadvantage  it  may  be 
called,  of  making  class  work  impossible,  for  the  patient  must  be 
under  constant  supervision,  not  only  that  he  may  be  urged  to 
the  limit  of  his  capacity,  but  that  overstrain  may  be  avoided 
as  well. 

It  might  appear  from  the  description  that  the  danger  of  over- 
work is  great,  but  in  a  long  series  of  cases,  some  of  which  were 
complicated  by  defects  of  the  heart  and  lungs,  no  unfavorable 
symptoms  have  been  observed  by  Teschner.  The  system  is,  how- 
ever, one  that  can  be  practised  only  by  a  physician. 

Another  system  of  exercises,  modified  somewhat  from  the  Swedish 
system,  more  suitable  for  class  work  is  that  followed  at  the  Hos- 
pital for  Ruptured  and  Crippled.  Dr.  Truslow  has  outlined  for 
me  some  of  the  more  important  exercises,  and  illustrated  them  with 
the  photographs  that  are  reproduced  here. 


TREATMENT 


193 


The  objects  of  the  treatment  are:  (1)   To  overcome  the  patient's 
faulty  habits  of  posture  by  the  repeated  purposeful  assumption  of 


i"iiiiri|-!;,i,\i. 


Fig.  158. — Typical  lateral  curvature.     Right  dorsal.     Left  lumbar. 


proper  postures;  in  other  words,  to  counteract  the  deformity  habit 
by  training  the  mental  and  muscular  perception  of  symmetry. 
13 


194  LATERAL   CURVATURE  OF   THE  SPIXE 

(2)  To  stimulate  and  to  strengthen  the  weakened  muscles,  particu- 
larly those  muscular  groups  that  are  especially  concerned  in  over- 
coming the  deformities,  and  which,  for  the  present  purpose,  may  be 
considered  as  weak. 

For  convenience  of  description  the  exercises  are  divided  into 
two  classes:  (1)  self-correction;  (2)  muscle  building. 

Exercises  in  Self-correction. — The  first  exercises  (a  and  b)  in 
self-correction  are  for  the  purpose  of  overcoming  the  antero- 
posterior deformities  that  usually  accompany  lateral  deviation 
of  the  spine. 

(a)  He-^d  Bexdixg  Backward. — In  this  exercise  the  chin  is 
not  tilted  upward,  but,  the  head  being  held  level,  the  neck  is  drawn 
directly  backward  until  the  cervical  and  upper  part  of  the  dorsal 
segments  of  the  spine  are  completely  extended.  Thus,  by  increas- 
sing  the  distance  between  the  points  of  attachment  of  the  sternomas- 
toids  and  the  scaleni,  strong  traction  is  made  upon  these  muscles 
with  the  effect  of  elevating  the  upper  part  of  the  thorax — an  impor- 
tant feature  in  the  exercise. 

(b)  Truxk  Bexding  Foewaed  axd  Truxk  Raisixg. — The 
patient  stands  in  the  erect  posture  with  the  spine  extended  and 
the  chest  expanded  as  in  the  previous  exercise.  The  trunk  is  then 
bent  forward  (similar  to  Fig.  163),  the  only  motion  being  at  the 
hip-joints.  The  trunk  is  then  raised  again  to  the  former  position, 
care  being  taken  to  keep'  the  hips  farther  back  than  the  chest. 
In  both  flexion  and  extension  the  spine  must  be  rigidly  held  in  the 
corrected  attitude,  and  there  must  be  no  motion  at  the  knees. 
There  is,  of  course,  a  movement  corresponding  to  extension  at  the 
ankle-joints  when  the  legs  and  buttocks  are  thro^m  backward  to 
compensate  for  the  forward  bending  of  the  body.  The  object  of 
this  exercise  is  to  train  the  patient  to  keep  the  hips  back  and  the 
chest  forward. 

The  other  exercises  in  self-correction  are  for  the  purpose  of 
overcoming  lateral  deviation  of  the  spine,  the  right  dorsal,  left 
lumbar  cmve  being  taken  as  the  tA-pe  (Fig.  158). 

This  series  is  arranged  in  a  progression,  and  each  one  must  be 
learned  before  the  next  in  order  is  attempted. 

(c)  Left  Neck  Firm. — The  left  hand  is  placed  behind  the  neck, 
the  left  shoulder  is  raised,  and  the  left  elbow  is  held  well  back. 
This  posture  impresses  upon  the  patient  the  necessity  of  approxi- 
mating the  left  shoulder  and  the  neck  (Fig.  159). 

(d)  Body  Ixclixatiox  to  the  Left. — This  is  a  most  important 
posture;  it  is  intended  to  correct  mechanically  the  faulty  inclina- 
tion to  the  right  and  to  overcome  the  upper  curve  by  traction  on 
its  concavity.  The  patient  holding  the  arm  in  the  first  position  is 
instructed  to  stretch  well  out  with  the  left  elbow,  rotating  upward 
and  abducting  the  left  scapula  as  much  as  possible.  This  puts 
upon  the  stretch  the  rhomboidei  and  the  lower  half  of  the  trapezius 


TREATMENT 


195 


of  the  left  side,  thus  making  strong  traction  upon  their  points  of 
attachment  in  the  dorsal  concavity.  At  the  same  time  the  patient 
is  directed  to  sway  the  pelvis  to  the  right.  This  usually  requires 
assistance  at  first,  for  it  brings  into  action  certain  deep  back  muscles, 
over  which  one  has  ordinarily  but  little  control.     The  shoulders 


Fig.  159. — Left  neck  firm. 


must  be  kept  level  and  the  proper  relation  of  the  head  and  neck 
to  the  left  shoulder  must  not  be  disturbed  in  this  forced  stretch  to 
the  left  (Fig.  160). 

(e)  Chest  Pressing  with  the  Right  Hand. — The  patient 
holding  the  left  arm  in  the  first  position  presses  the  right  hand 
firmly  against  the  dorsal  convexity.     This  posture  may  be  employed 


196 


LATERAL  CURVATURE  OF   THE  SPINE 


to  advantage  if  there  is  a  long  right  dorsal  curve,  when  it  is  an 
efficient  aid  to  the  left-sided  pull  of  the  two  former  exercises. 

(/)  Right  Neck  Firm. — The  right  hand  is  placed  behind  the 
neck,  without,  however,  disturbing  the  improved  position  induced 
by  the  first  exercises.  With,  both  hands  placed  behind  the  head, 
the  arms  being  in  a  symmetrical  position,  there  is  better  mechanical 


Fig.   160. — Body  inclination  to  the  left. 

fixation  of  the  head,  neck,  and  upper  part  of  the  trunk  during  the 
next  exercise  (Fig.  161). 

(g)  Left  Hip  Twisting  Backward. — In  posture  (d)  the  pelvis 
was  swayed  slightly  to  the  right;  it  is  now  twisted  slightly  back- 
ward on  the  left  side  to  overcome  the  twist  in  the  lumbar  spine 
which  usually  throws  this  side  of  the  pelvis  somewhat  forward. 
This  correcting  motion  should  be  carried  out  in  the  lower  dorsal 


TREATMENT 


197 


and  lumbar  segments,  and  it  should  not  affect  the  attitude  of  the 
remainder  of  the  trunk. 

(/i)  Left  Oblique  Stride  Standing. — The  pelvic  twist  and 
right-sided  sway  being  rigidly  maintained,  the  left  foot  is  placed 
about  two  foot-lengths  forward  and  a  little  outward.  Upon  this 
leg  the  greater  part  of  the  weight  of  the  body  is  now  supported. 
This  allows  a  slight  downward  tilt  of  the  pelvis  to  the  right,  and 
lessens  the  left  lumbar  convexity  (Fig.  162).     The  positions  attained 


'''M'v''  .''■■''      ■■■■■■  1 
V'./'.- 1-'."..'."  "'.'■"  I 


■'l 

Py-y-rr 


"■■■l.,iT    -ll-li    11      1      , 

§..    '■#'■.', ."„■'."' 
•iffi./,"..;..'.,  ,."„■■ 


Fig.   161. — Right  neck  firm. 


by  the  progressive  exercises  to  this  point  being  maintained,  the 
patient  continues  with — 

{i)  Trunk  Bending  Forward. — In  this  posture  motion  takes 
place  in  the  hip-joints  only,  as  in  the  first  exercise.  This  exercise 
further  emphasizes  the  symmetrical  position  of  the  head  and  neck, 
the  left-sided  inclination  of  the  upper  half  of  the  trunk,  the  right- 
sided  inclination  of  the  lower  half,  the  twist  and  downward  tilt 
of  the  pelvis  (Fig.  163).  The  return  to  the  improved  standing 
position  should  be  made  in  this  order:  (1)  trunk  raising;  (2)  replace- 


198  LATERAL  CURVATURE  OF   THE  SPINE 

ment  of  the  left  foot;  (3)  return  of  both  arms  to  the  sides.  This 
is  done  slowly  and  carefully  by  the  patient,  who  attempts  to  main- 
tain the  improved  posture. 


Fig.   162, — Left  oblique  stride  standing. 

The  postures  constitute  a  progression  which  cannot  be  learned 
in  less  than  seven  treatments;  often  much  more  time  is  required. 


TREATMENT 


109 


As  each  part  is  learned  it  should  be  practised  at  home  until  the  next 
treatment,  when  a  new  posture  is  added,  if  it  appears  that  progress 
can  be  made. 


immmm\mimMi»ii 


Fig.   163. — Trunk  bending  forward. 


These  successive  postures  are  in  reality  exercises  in  that  it  requires 
constant  muscular  effort  to  retain  them,  but  they  are  not  exercises 
in  the  sense  of  repeated  alternations  of  position.  The  series  is 
simply  an  elaboration  of  what  is  called  the  key-note  posture.  The 
raising  of  the  left  elbow,  for  example,  makes  it  easier  for  the  patient 
to  overcome  the  distortion  of  the  upper  part  of  the  spine;  it  also 


200  LATERAL   CURVATURE  OF   THE  SPIXE 

instructs  him  in  the  manner  of  holding  the  spine  in  the  improved 
position  after  the  arm  is  placed  by  the  side. 

The  same  is  true  of  all  the  postures;  each  one  suggests  and  makes 
correction  easier,  and  after  sufficient  practise  the  patient  should 
be  able  to  assume  the  correct  position  without  placing  the  arm  or 
the  leg  in  the  preliminary  attitude.  Thus  the  successive  postures, 
are,  as  it  were,  letters,  which,  placed  together  one  by  one,  make  a 
complete  word,  or  the  best  possible  position  that  the  patient  can 
assume.  At  first  the  patient  must  use  the  letters  and  slowly  spell 
out  the  corrected  attitude,  but  after  the  muscles  have  been  educated 
by  the  repeated  assumption  of  each  posture,  and  when  the  perception 
of  symmetry  has  been  acquired,  the  corrected  attitude  may  be  as- 
sumed at  will.  Finally,  the  improved  posture  will  be  instinctively 
retained,  and  will  become  habitual. 

Muscle-building  Exercises. — In  the  treatment  of  lateral  curvature 
one  aims  to  strengthen: 

1.  The  posterior  cervical  muscles. 

2.  The  dorsal  and  lumbar  muscles. 

3.  The  muscles  of  vertebroscapular  attachment. 

4.  The  abdominal  muscles. 

5.  The  thigh  and  leg  muscles. 

6.  The  chest  expanding  muscles. 

The  following  exercises  have  been  selected  as  best  adapted  for 
this  purpose.  Each  one  should  be  performed  five  or  more  times 
according  to  the  strength  of  the  patient. 

(a)  Opposite  Standing,  Head  Bent^ing  'Backward,  Re- 
sisted.— ^The  patient  stands  before  a  wall  or  a  shoulder-high 
horizontal  bar,  on  which  the  hands  are  placed  with  the  arms  ex- 
tended. The  head  is  bent  forward,  and  is  then  forced  backward, 
the  latter  movement  being  resisted  by  the  hand  of  the  surgeon. 
This  exercise  is  designed  to  strengthen  the  posterior  cervical 
muscles. 

(b)  Opposite  Bend  Stant)ing,  Trunk  Raising,  Resisted. — 
The  patient  stands  with  the  upper  part  of  the  thighs  in  contact 
with  a  table  or  horizontal  bar.  The  hands  are  placed  behind  the 
neck  and  the  body  is  bent  forward  on  the  hip-joints  as  in  the  first 
exercise.  The  surgeon,  standing  behind,  places  his  right  hand  over 
the  posterior  dorsal  prominence  and  his  left  over  the  lumbar  pro- 
jection. The  patient  then  raises  the  trunk  to  the  erect  position 
against  the  combined  resistance  (Fig.  16-4).  With  a  little  practise 
the  surgeon  learns  to  give  an  outward  twisting  motion  to  his  hands 
while  resisting,  which  tends  to  untwist  the  spinal  rotations.  When 
the  dorsal  rotation  to  the  right  is  marked  this  untwisting  may  be 
facilitated  by  encircling  the  patient's  chest  with  the  left  hand,  while 
with  the  right,  strong  forward  and  outward  pressure  is  made  as  the 
patient  raises  the  body.  This  exercise  is  for  the  purpose  of  develop- 
ing the  muscles  of  the  erector  spinee  group. 


TREATMENT 


201 


(c)  Prone  Lying,  Head  and  Shoulder  Raising  "the  Seal." — 
The  patient  lies  upon  a  table  or  upon  the  floor,  and  raises  the  head 
and  chest — "looks  at  the  ceiling."  Progression  is  made  in  the 
increased  leverage  of  arm-weight  transference. 


Fig.   164. — "Opposite  bend  standing,"  trunk  raising,  resisted. 


1.  With  the  hands  on  the  backs  of  the  thighs. 

2.  With  the  left  hand  behind  the  neck  and  the  right  hand  on 
the  back  of  the  thigh. 


202 


LATERAL  CURVATURE  OF   THE  SPIXE 


TREATMENT  203 

3.  With  both  hands  behind  the  neck,  and  with  the  elbows  well 
out  and  back. 

4.  "Swimming."  The  arm  motions  of  swimming,  in  three 
counts.  This  exercise  is  to  strengthen  the  muscles  of  the  back 
from  the  head  to  the  pelvis. 

(d)  Prone  Lying,"  Diving." — The  patient  lies  upon  a  table 
the  trunk  and  pelvis  projecting  beyond  its  edge,  the  limbs  being 
fixed  by  a  strap  or  the  weight  of  another  person.  The  body  is 
then  bent  downward  and  is  raised  again  to  the  horizontal  position 
(Fig.  165).  In  this  exercise  assistance  will  be  required  at  first. 
Progression  is  made  by  transference  of  arm  weights,  as  in  the 
former  exercise,  thus: 

1.  With  the  hands  on  the  hips. 

2.  With  the  arms  stretched  out  at  right  angles  to  the  body. 

3.  With  the  hands  behind  the  neck. 

4.  With  the  arms  extended  in  the  line  of  the  body. 

This  exercise  is  for  the  purpose  of  strengthening  all  the  muscles 
of  the  back. 

(e)  Prone  Lying,  Leg  Raising. — The  patient,  lying  in  the 
prone  posture  upon  the  floor  or  table,  lifts  the  limbs  (overextends) 
alternately,  the  raised  leg  held  perfectly  straight.  When  the  left 
thigh  is  extended,  as  much  as  the  iliofemoral  ligament  will  allow, 
the  left  side  of  the  pelvis  is  tilted  upward  also,  thus  untwisting  the 
lumbar  spine.     Progression  in  this  exercise  is  made  as  follows: 

L  Alternate  leg  raising,  unresisted. 

2.  Alternate  leg  raising,  resisted. 

3.  The  leg  motions  of  swimming  in  three  counts. 

In  this  exercise  the  entire  lower  extremities  must  project  be- 
yond the  supporting  table.  The  exercises  are  for  the  purpose 
of  strengthening  the  lumbar  muscles  and  the  extensors  of  the  thigh. 

(/)  Opposite  Sitting,  Backward  Bending  of  the  Trunk. — 
The  patient  is  seated  upon  a  bench,  and  the  feet  are  fastened  to 
the  floor.  The  trunk  being  held  in  a  position  of  complete  exten- 
sion, is  bent  slowly  backward,  motion  being  at  the  hip-joint  only. 
Progression. 

1.  With  the  hands  behind  the  hips. 

2.  With  the  left  hand  behind  the  neck,  the  right  hand  on 
the  hip. 

3.  With  both  hands  behind  the  neck. 

4.  With  both  arms  extended  upward. 

At  first  the  body  is  bent  backward  about  forty-five  degrees, 
later  until  the  head  touches  the  floor.  This  exercise  is  to  strengthen 
the  abdominal  muscles. 

(g)  The  Horizontal  Bar.  "Pull-ups." — The  patient  hangs 
by  the  hands  and  is  assisted  to  "chin  the  bar."  The  body  is  then 
allowed  to  sink  slowly  back  into  the  former  position,  the  elbows 
are  held  well  back,  and  the  patient  is  instructed  to  bear  as  much 


204  LATERAL  CURVATURE  OF   THE  SPINE 

of  the  weight  as  is  possible  with  the  left  arm  and  shoulder.  This 
exercise  corrects  the  dorsal  curve  by  means  of  muscular  activity, 
and  the  lumbar  curve  by  the  weight  of  the  suspended  pelvis  and 
limbs.  The  muscles  used  are  those  with  vertebroscapula  attach- 
ment. 

(/?)  Left  Leg  Standing,  Pelvis  Tilting. — The  patient  stands 
upon  the  edge  of  a  bench,  supporting  the  weight  on  the  left  leg, 
the  right  leg  being  suspended  beyond  the  side  of  the  bench.  While 
the  head  and  trunk  are  kept  in  the  corrected  position,  the  pelvis 
is  made  to  tilt  sharply  downward  on  the  right,  by  lowering  the  right 
leg,  while  the  left  is  kept  perfectly  stift'.  This  has  the  effect  of 
straightening.the  lumbar  curve. 

(i)  Left  Leg,  "Hopping." — Both  hands  are  placed  behind 
the  neck  and  the  weight  is  supported  entirely  upon  the  ball  of  the 
left  foot.  In  this  attitude  the  patient  hops  ten  or  more  times. 
This  exercises,  like  the  last,  tends  to  straighten  the  spine  and  to 
strengthen  the  muscles  of  the  left  leg,  which  are  often  somewhat 
weakened  from  disuse. 

(j)  Respiratory,  Half  Reclining,  Arm  Extensions  ant) 
Flexions,  Resisted. — The  patient  sits  in  a  chair  with  an  inclined 
back,  or  lies  upon  a  low  table  with  hard  pillows  under  the  mid- 
dorsal  region,  so  that  the  upper  dorsal  and  cervical  segments  of  the 
spine  must  be  overextended.  The  arms  are  stretched  upward  and 
backward,  and  the  hands  are  grasped  by  the  surgeon,  who  stands 
behind  and  resists  the  patient's  downward  pull.  With  the  upward 
stretch  of  the  arms  and  pull  by  the  surgeon  the  patient  inhales 
forcibly.  With  the  downward  pull  against  resistance  the  patient 
exhales  forcibly.  This  exercise  is  made  in  the  rhythm  of  slow 
breathing. 

When  the  patient  has  been  thoroughly  instructed  in  self-correction 
and  in  the  exercises  for  muscle  building,  general  gymnastics  for 
systematic  motor  training  may  be  given  effecti^'ely  to  groups  of 
fifteen  or  twenty  puplis. 

The  exercises  illustrated  on  pages  ISO  to  187  will  serve  this 
purpose  satisfactorily. 

These  two  systems  of  treatment  by  g^^Ilnastics  have  been  selected 
as  the  most  practicable  of  the  many  that  have  been  devised.  It 
may  be  stated  that  any  treatment  that  makes  the  spine  more 
flexible,  that  overcomes  faulty  attitudes,  and  that  strengthens  the 
muscles,  must  be  of  service  to  the  patient,  the  degree  of  benefit 
corresponding  to  the  persistence  and  energy  of  the  pupil  and  the 
instructor  rather  than  to  any  particular  theory  on  which  such  treat- 
ment is  based.  The  rotation  of  the  vertebral  bodies  is  increased  by 
forward  bending  of  the  trunk,  and,  as  this  is  the  more  important 
element  of  lateral  curvature,  it  is  evident  that  extension  or  over- 
extension of  the  spine,  combined  with  lateral  twisting  in  such  a 
manner  as  to  reverse  the  habitual  inclination,  will  most  directly 


TREATMENT 


205 


Fig.   166. — Lateral  curvature. 


Fig.  167. — The  same  patient,  showing  fixed  rotation  to  the  right  in  the  thoracic 
region.  (See  Figs.  168  and  169,  illustrating  a  simple  corrective  exercise  that  may  be 
carried  out  by  the  patient.) 


206  LATERAL  CURVATURE  OF  THE  SPINE 


Fig.   168.— The  patient  shown  in  Figs.  167  and  168  inclines  the  body  to  the  right 
pressing  the  projecting  ribs  in  with  the  right  hand.     (See  Fig.  165.) 


Pjq    i69_ — In  the  picture  shown  in  Fig.  167,  the  patient  incUnes  the  body  forward. 
The  correction  is  illustrated  by  comparison  with  Fig.  169  in  the  same  position. 


TREATMENT  207 

lessen  or  correct  the  distortion.  Exercises  of  this  character  are  far 
more  effective  than  are  elaborate  systems  of  general  gymnastics 
(Figs.  168  and  169). 

Corrective  Treatment  Combined  with  Support. — It  should  be  evi- 
dent that  treatment  by  gymnastic  exercises,  during  which  the  de- 
formity is  but  partly  corrected  and  after  which  it  is  permitted  to 
recur,  cannot  be  curative.  From  this  treatment  one  may  hope  for 
such  improvement  in  the  general  condition,  in  the  muscular  strength 
and  in  the  ability  to  hold  the  body  at  will  in  better  position  as  will 
check  the  progress  of  the  deformity  and  mitigate  or  conceal  its 
effects. 

In  cases,  therefore,  of  resistant  deformity,  or  when  for  any 
reason  simple  gymnastic  treatment  is  unsatisfactory,  the  following 
method  of  forcible  methodic  correction  combined  with  support 
may  be  employed  with  advantage. 

The  plaster  corset  is  the  most  practicable  support  because  it 
may  be  applied  directly  by  the  one  who  conducts  the  treatment 
and  thus  it  may  be  modified  and  renewed  at  frequent  intervals. 

It  should  be  applied  in  the  upright  attitude  as  described  under 
Pott's  Disease.  By  suspension  the  normal  relation  of  the  trunk  to 
the  pelvis  may  be  restored  in  great  degree  and  the  direct  deformity 
in  part  reduced. 

The  corset  should  press  upon  the  projecting  ribs,  but  not  upon 
the  flattened  part  of  the  trunk,  depressions  therefore  should  be 
filled  by  padding  beneath  the  shirt.  If  the  patient  is  a  female, 
pads  of  cotton  should  be  placed  below  and  in  front  of  the  breasts 
to  prevent  pressure.  A  plaster  jacket  is  applied  in  the  usual  man- 
ner, the  deformity  being  further  corrected  by  pressure  with  the 
hands  during  the  hardening  stage.  It  is  then  removed  and  is 
bound  and  fitted  with  hooks  for  lacing. 

The  patient  is  provided  with  an  apparatus  for  self-suspension 
so  that  the  corset  may  be  removed  and  adjusted  in  the  original 
position. 

The  active  treatment  is  conducted  somewhat  as  follows:  The 
patient  is  placed  face  downward  on  a  narrow  table,  in  the  absence 
of  assistance  clasping  it  with  the  arms  to  fix  the  thorax.  One  then 
attempts  to  reduce  and  if  possible  to  overcorrect  the  deformity 
by  hyperextension,  and  by  lateral  flexion  of  the  trunk.  Thus,  if 
the  primary  lumbar  curvature  is  to  the  left,  the  operator  standing 
on  this  side  of  the  table  and  with  the  left  hand  pressing  downward 
on  the  convexity,  with  the  other  lifts  the  right  thigh  of  the  patient, 
hyperextends  it  and  draws  it  upward  and  toward  the  left,  lifting 
and  turning  the  pelvis  in  a  manner  to  untwist  the  spine  (Fig.  170). 

This  movement  is  carried  out  over  and  over  again  in  the  "pump 
handle"  manner,  the  patient  assisting  and  eventually  gaining  the 
ability  to  throw  the  limb  backward  and  to  the  side  without  assist- 
ance.    The  dorsal  curvature  is  corrected  in  the  same  manner  by 


208  LATERAL  CURVATURE  OF   THE  SPINE 

passing  the  arm  beneath  the  thorax  of  the  patient,  hyperextendng 
the  trunk  and  at  the  same  time  rotating  it  in  a  manner  to  overcome 
the  deformity.  The  manipulation,  lasting  about  twenty  minutes, 
should  be  repeated  at  least  twice  daily;  the  corset  is  then  applied 
and  it  may  be  worn  with  advantage  during  the  night  (Fig.  172). 

As  the  spine  becomes  more  flexible  so  that  it  may  be  still  further 
corrected,  new  corsets  are  applied.  During  the  day  self-suspension 
at  intervals  is  of  service  and  the  patient  should  from  time  to  time 
assume  the  key-note  posture,  endeavoring  to  correct  the  deformity 
beyond  the  degree  enforced  by  the  corset.  ]Massage  of  the  muscles 
of  the  trunk  and  self-correction  exercises  are  useful  in  supplemental 
treatment. 


Fig.   170. — Correction  of  a  left  lumbar  rotation  by  natural  leverage. 

By  this  method  a  continuous  and  satisfactory  improvement  is 
usually  apparent.  Eventually  the  plaster  support  may  be  replaced 
by  an  ordinary  stiffened  corset. 

In  this  method  of  treatment  the  plaster  corset  serves  only  as  a 
retention  brace,  the  correction  of  the  deformity  being  accomplished 
by  the  manipulation  and  exercises.  In  other  instances  when  the 
supplementary  treatment  is  impracticable,  as  in  the  hospital  class, 
a  fixed  jacket  may  be  employed,  more  corrective  force  being  used 
in  its  application. 

For  example,  the  patient  may  be  suspended  in  the  prone  posture 
on  a  strip  of  cotton  cloth  (the  hammock  method).  As  this  sinks 
under  the  weight  the  trunk  falls  into  the  attitude  of  o^■erextension 
which  is  desirable  in  cases  in  which  posterior  curvature  is  marked. 


TREATMENT 


209 


or  the  body  may  be  suspended  in  the  lateral  attitude  by  means  of 
a  sling  of  cotton  cloth  passed  about  the  prominent  ribs;  so  that 


Fig.  171. — Correction  of  a  left  lumbar  curvature  by  natural  leverage,  illustrating  the 
application  of  greater  force. 


Fig.   172. — Correction  of  a  left  dorsal  curvature  by  natural  leverage. 


the  weight  of  the  body  acts  as  a  correcting  force  during  the  appli- 
cation of  the  corset. 
14 


210 


LATERAL   CURVATURE  OF   THE  SPINE 


In  using  such  corrective  force  one  endeavors,  if  possible,  to  over- 
correct  the  habitual  deformity  and  the  less  marked  changes  in  the 
anteroposterior  contour  as  well.  For  example,  if  the  lumbar 
region  is  flat  one  attempts  to  reproduce  the  normal  lordosis,  and  if 
the  body  is  habitually  inclined  in  one  direction  one  endeavors  to 
sway  it  to  the  opposite  side,  and  to  efface  the  so-called  high  hip. 
These  jackets  are  changed  at  frequent  intervals.  They  are  particu- 
larly indicated  in  deformity  of 
the  paralytic  or  rhachitic  t\'pe 
in  young  subjects. 

A  better  form  of  fixed  support 
is  the  jacket  applied  after  the 
Calot  method  in  which  correc- 
tive pressure  is  made  by  means 
of  pads,  a  "window"  having 
been  cut  out  on  the  flattened  or 
concave  side  to  permit  expan- 
sion. In  treatment  by  fixed 
supports  in  which  pressure  is 
exerted  on  the  deformity  and 
space  provided  for  correction, 
the  respiratory  movements  of 
the  chest  are  an  aid  in  rectifi- 
cation. Greater  corrective  force 
may  be  applied  by  machines  as 
illustrated  in  Fig.  173,  the  jacket 
being  applied  to  include  the 
pressure  pads. 

The  Abbott  Treatment. — It  has 
been  stated  that  cure  of  the  de- 
formity of  the  spine  as  elsewhere 
implies  primary  overcorrection, 
fixation  for  a  time  sufficient  to 
permit  accommodation    to  the 
new  psition,  and  finally  the  re- 
establishment  of   the   muscular 
balance  in  order  to  maintain  it. 
Although  the   application  of 
the     principle     had    been    at- 
tempted   by    Hoffa,    Wullstein 
and  many  others,  it  had  always  been  considered  impracticable  in 
the  great  majority  of  cases  for  various  reasons. 

In  1911  Dr.  E.  G.  Abbott^  announced  that  the  problem  of  eflS- 
cient  treatment  had  been  solved  and  in  a  subsequent  article,-  repre- 
senting two  years  of  work,  he  presented  his  conclusions  as  follows: 


Fig.  173.  —  Forcible  correction  by 
means  of  the  modified  Hoffa  appliance. 
(Bradford    and    Brackett.) 


1  New  York  Med.  Jour.,  June  24,  1911. 


Ibid.,  April  27,  1912. 


TREATMENT  211 

"In  a  previous  article  the  statement  was  made  that  fixed  lateral 
curvatures  of  the  spine  yielded  to  treatment  as  easily  as  bow-legs 
or  club-feet.  Further  experience  has  led  me  to  believe  that  this 
deformity  yields  far  more  readily  than  either  of  the  others." 

Dr.  Abbott  in  support  of  his  contention  presented  the  logical 
proposition  that  flexing  and  thus  relaxing  the  spine  was  the  first 
essential  of  correction,  and  that  forcible  correction  had  thus  far 
been  ineffective  because  it  had  been  attempted  with  the  spine 
extended.  *For  although  Lovett^  had  called  attention  to  the  fact 
that  relaxation  favored  the  reduction  of  rotation  and  had  applied 
jackets  with  the  patient  supported  in  the  prone  position,  forced 
flexion  had  apparently  never  been  attempted. 

The  novelty  of  a  method  applying  surgical  principles  supported 
by  unqualified  statements  of  its  success  in  the  treatment  of  fixed 
lateral  curvature,  a  class  of  cases  considered  as  incurable,  attracted 
wide  attention,  and  it  will  be  presented  in  Dr.  Abbott's  words. 

"Lateral  curvature  is  a  simple  deformity  which  can  be  created 
artificially  and  as  easily  corrected. 

"To  effect  a  cure  the  spine  must  be  flexed  and  drawn  to  one  side 
by  force  exerted  in  the  direction  opposite  to  that  of  the  fixed  curve 
and  that,  together  with  this,  the  low  shoulder  and  the  depressed 
ribs  must  be  elevated  and  forced  into  a  position  posterior  to  that 
of  the  high  shoulder,  and  bulging  ribs  in  a  patient  must  be  placed 
in  a  position  which  is  exactly  opposite  to  that  of  the  original  deform- 
ity, and  that  with  the  spine  flexed." 

This  attitude  was  attained  by  placing  the  patient  on  the  back 
in  a  sagging  hammock  and  then  forcing  the  trunk  into  an  attitude 
of  apparent  overcorrection  by  the  tension  of  bands  passed  about 
it.  A  plaster  jacket  was  then  applied  in  which  openings  were  sub- 
sequently made  to  permit  further  correction  by  the  insertion  of 
pads,  as  in  the  Calot  method  for  the  correction  of  the  deformity  of 
Pott's  disease. 

Abbott's  detailed  description  of  the  application  of  the  jacket  on 
the  frame  then  employed  is  as  follows: 

A  frame  and  hammock  similar  to  those  in  applying  corsets  in 
Pott's  disease  is  employed. 

The  frame  is  made  of  gas  pipe  in  the  usual  dimensions:  Length, 
five  and  one-half  feet;  width,  twenty-six  inches;  and  height,  thirty 
inches. 

The  front  legs  are  so  constructed  that  they  may  be  shortened 
twelve  inches,  while  the  rear  ones  may  be  lengthened  eighteen 
inches.  Across  the  front  at  the  top  is  a  rod  of  half-inch  steel  to 
w^hich  is  attached  one  end  of  the  hammock.  In  a  similar  position 
at  the  rear  is  a  windlass  with  a  ratchet,  over  which  pass  two  cords 
about  three  feet  in  length  terminating  in  loops,  which  slip  over  the 

1  Lateral  Curvature  of  the  Spine,  Boston,  1907. 


212  LATERAL  CURVATURE  OF   THE  SPINE 

extremities  of  another  steel  rod,  which  is  passed  through  the  hem 
of  the  other  end  of  the  hammoct.  By  this  means  the  hammock  is 
held  in  a  horizontal  position  and  can  be  stretched  or  made  to  sag 
at  will.  A  movable  crosspiece  of  iron  about  three  inches  wide  is 
placed  across  the  frame  near  its  centre  beneath  the  hammock.  To 
this  crosspiece  is  attached  a  light  framework  about  two  and  one- 
half  feet  long  made  of  half -inch  iron,  the  rear  end  of  which  may  be 
raised  and  held  at  any  angle  by  a  prop.  BetwecD  the  upper  side 
rails  of  the  frame  about  six  inches  from  its  forward  end  and  just 
beneath  the  hammock  is  stretched  a  two-inch  strap  of  leather  or 
webbing. 


Fig.   174. — Frame,  -nith  hammock  hanging  on  the  wall. 

The  hammock  itself  is  made  of  light  duck  about  a  yard  in  length 
and  fifteen  inches  in  width,  and  is  cut  diagonally  across  its  head 
(Fig.  174).  Its  ends  are  turned  over  and  sewed  firmly,  leaving  a 
hem  through  which  may  be  passed  the  steel  rods  which  hold  it  to 
the  frame.  When  the  hammock  is  placed  on  the  frame,  as  one  side 
is  seven  and  one-half  inches  shorter  than  the  other,  it  is  straight 
or  nearly  so  on  the  short  side,  while  on  the  long  side  it  sags  several 
inches  (Fig.  175). 

A  cradle  is  thus  formed  in  which  a  patient  may  be  put  and  forced 
into  an  overcorrected  position.  The  buttocks  are  placed  upon  the 
crosspiece;  the  head  rests  upon  the  front  of  the  hammock;  the 


TREATMENT 


213 


strap  supports  the  neck;  the  straight  side  of  the  hammock  pushes 
the  bulging  ribs  forward;  the  long  side  gives  room  for  the  depressed 
ribs  to  be  pushed  backward;  the  framework  on  which  the  lower 
limbs  rest  elevates  them:  and  the  adjustable  legs  allow  of  tilting 
the  frame,  so  that  the  body  weight  will  assist  in  forcing  the  patient 
into  the  desired  position. 

In  preparing  the  patient  considerable  care  is  necessary  in  order 
that  the  corset  may  not  irritate  the  skin  or  cause  sloughing  of  the 
tissues. 

Saddler's  felt  is  used  for  pads  over  all  bony  prominences.  The 
rule  followed  in  the  Children's  Hospital  is  to  put  two  undervests 
on  the  patient  so  that  the  pads  may  be  placed  between  them  rather 


Fig.  175, — Frame,  with  hammock  attached. 


than  next  to  the  corset.  Thus  the  felt  is  not  destroyed,  and  it  is 
much  easier  to  insert  more,  if  necessary,  to  bend  the  body  in  the 
desired  direction.  It  is  very  essential  to  place  heavy  pads  over 
the  following  places:  Back  of  the  low  shoulder,  over  the  sacrum, 
over  the  spinous  processes  of  the  ilium,  over  the  prominent  ribs  at 
the  front  of  the  thorax,  under  both  arms,  and  over  the  convexity 
of  the  ribs  where  the  band  is  applied  to  make  lateral  traction.  If 
the  patient  is  thin,  it  is  advisable  to  supplement  the  body  covering 
by  winding  sheet  wadding  over  the  entire  body  surface  covered  by 
the  corset. 

The  patient,  having  been  prepared  in  the  manner  described 
above,  is  ready  to  be  placed  upon  the  frame.    Here  it  is  of  the  great- 


214 


LATERAL  CURVATURE  OF   THE  SPINE 


est  importance  that  the  most  fa\'orable  position  be  secured,  which 
is  the  same  as  that  assumed  by  a  person  sitting  obhquely  at  a 
desk.     Xo  other  will  produce  the  results. 


Fig.   176. — Frame,  with  patient  placed  on  it. 


Fig.  177. — Frame  and  patient  with  straps  adjusted. 


TREATMENT 


215 


The  patient  is  lifted  from  a  nearby  table  on  which  he  has  been 
prepared,  and  carefully  placed  on  the  hammock  face  upward 
(Fig.  176).  The  shorter  side  of  the  hammock  presses  against  the 
bulging  ribs,  and  the  depressed  ribs  sag  downward  against  the  long 
side.  The  back  of  the  neck  rests  across  the  strap  of  webbing,  and 
the  head  lies  on  that  portion  of  the  hammock  between  the  strap 
and  the  steel  rod  over  which  the  hem  is  passed.  The  buttocks  rest 
upon  the  iron  crosspiece,  which  is  adjustable  and  slides  over  the 
frame  so  that  any  length  of  the  hammock  may  be  used,  according 
to  the  body  length  of  the  patient.  Straps  are  now  applied  around 
the  body  to  pull  it  in  the  desired  direction  (Fig.  177).  One  is  placed 
beneath  the  axilla  of  the  low  shoulder, 
and  carried  across  the  frame  obliquely 
to  the  opposite  front  corner.  When 
this  strap  is  tightened  it  not  only 
draws  the  upper  end  of  the  deformed 
spine  toward  the  side  of  the  frame  to 
which  the  strap  is  fastened,  but  it 
also  elevates  the  low  shoulder.  A 
second  strap,  passed  around  the  but- 
tocks in  the  same  manner  that  the 
first  is  passed  under  the  axilla,  is 
carried  across  the  frame  in  an  oblique 
direction  toward  the  rear  end  and 
tightened.  This  draws  the  lower  ex- 
tremity of  the  body  toward  the  same 
side  of  the  frame  that  the  axillary 
strap  does.  The  next  strap  is  passed 
around  the  patient's  body  over  the 
most  convex  portion  of  the  dorsal 
lateral  curve  and  around  the  upper 
rail  of  the  frame,  so  that  when  traction 
is  made  upon  it  the  lateral  curve  is 
obliterated  or  a  lateral  curve  in  the 
opposite    direction    is     made.      The 

fourth  strap  may  or  may  not  be  used.  If  the  curve  is  extremely 
rigid  and  a  rapid  reduction  of  the  deformity  is  desired,  it  is 
necessary.  On  the  other  hand,  if  time  is  of  little  consequence,  and 
the  patient  is  not  in  good  condition,  the  use  of  this  extra  force 
is  not  advisable.  The  same  final  result  is  obtained  with  or 
without  it.  It  is  put  in  place  by  first  passing  it  around  the  upper 
rail  of  the  frame  on  the  side  to  which  the  buttocks  and  axilla 
straps  are  fastened.  This  strap  should  be  at  least  four  inches 
wide  and  of  sufficient  length  to  pass  across  and  down  over  the  side 
of  the  patient's  body  and  to  allow  the  hanging  of  weights  upon  its 
end.  This  strap  is  for  the  purpose  of  bringing  force  against  the 
anterior  protruding  ribs,  so  that  they  may  be  forced  downward 
against  the  sagging  long  side  of  the  hammock  (Fig.  178). 


Fig.   178. — Frame   and   patient 
with  straps  adjusted. 


216 


LATERAL  CURVATURE  OF  THE  SPINE 


The  arms  of  the  patient  are  placed  in  the  following  positions: 
The  one  on  the  side  of  the  low  shoulder  is  elevated  as  much  as 
possible,  and  preferably  held  in  that  position  by  an  assistant  or 
nurse.  The  other  is  allowed  to  rest  on  the  frame  rail  in  a  position 
which  is  a  little  less  than  at  right  angles  with  the  body.  Weights, 
if  they  are  used,  are  now  attached  to  the  free  end  of  the  strap 
which  extends  across  the  body  for  the  purpose  of  forcing  the  ribs 
downward,  and  also  to  the  strap  which  makes  the  lateral  traction, 
so  that  it  will  be  pulled  away  from  the  body  and  not  left  against  the 
hammock.  The  frame  is  then  tilted  so  that  the  body  weight  may 
be  utilized  to  exaggerate  the  position.  The  original  frame  was 
afterward  discarded.  The  weight  and  the  inclination  often  employed 
to  increase  the  flexion  of  the  trunk  being  replaced  by  tension  straps 
and  by  the  elevation  of  the  legs,  as  illustrated  in  the  figures  from 
photographs  kindly  furnished  by  Dr.  Abbott. 


Fig.  179. — Frame  and  patient  with  straps  adjusted. 

"  If  it  is  intended  to  make  the  overcorrection  at  once  (and  this  is 
often  possible),  or  if  it  seems  better  gradually  to  swing  the  parts 
into  such  a  position  by  using  several  corsets,  the  patient  is  now 
fully  prepared  for  the  application  of  the  plaster  of  Paris. 

"  If,  however,  it  is  preferred  in  a  difficult  case  to  make  the  com- 
plete overcorrection  with  a  single  corset,  it  is  necessary  to  apply 
a  thick  OA^al-shaped  pad  of  felt  over  the  concave  side  and  back 
of  the  body,  so  that  when  the  window  is  cut  in  the  corset  this  pad 
may  be  removed  and  the  corset  left  in  suitable  shape  to  allow  the 
ribs  to  push  backward  and  the  spine  to  overcorrect  when  pads  are 
placed  in  the  front  and  sides. 


TREATMENT 


217 


Fig.  180.  —  Permanent  posterior 
pads,  these  are  placed  over  the  bear- 
ing surfaces  and  remain  in  the  plaster 
corset. 


Fig.  181. — Permanent  anterior  pads 
6  and  7  are  placed  over  the  anterior 
spinous  processes  to  prevent  chafing,  5 
is  placed  over  the  thorax  and  against 
this  pad  pressure  is  made  to  increase  the 
flexion  by  inserting  felt  through  the 
windows  in  the  corset. 


Fig.  182. — Removable  pads.  These  pads  are  used  in  addition  to  the  permanent 
posterior  pads  and  are  for  the  purpose  of  shaping  the  corset  so  that  the  patient  can 
be  forced  in  the  direction  of  overcorrection  as  illustrated  in  Fig.  186. 


218 


LATERAL   CURVATURE  OF   THE  SPIXE 


"  The  plaster  of  Paris  is  applied  in  the  same  way  as  in  any  plaster 
corset,  with  the  exception  that  over  the  elevated  shoulder  it  is 
extended  posteriorly  up  to  a  level  with  the  acromion  process.  In 
trimming  it,  the  bottom  is  cut  shorter  in  front  than  in  the  ordinary 
corset  and  longer  behind,  in  order  that  full  flexion  may  be  easily 
maintained  when  the  patient  sits  or  stands.  At  the  upper  end  it  is 
trimmed  very  high  beneath  the  ele\'ated  arm,  but  is  cut  away  on 
that  side  in  front,  so  that  the  shoulder  may  come  forward.  Beneath 
the  other  arm  it  is  trimmed  low,  being  left  high  in  front  so  that  this 
shoulder  cannot  drop  forward,  and  cut  out  behind  so  that  the 
shoulder  may  push  backward. 


Fig.  183. — The  straps,  which  when  attached  to  the  frame  pull  the  patient  in  the 
direction  of  the  normal  scoliotic  posture  opposed  to  the  deformity  posture,  are  passed 
around  the  patient  over  the  felt  pads  shown  in  Figs.  180  and  182. ^ 

"  Two  large  windows  are  cut  in  the  corset,  one  behind  and  another 
in  front.  The  former  is  made  as  large  as  possible.  It  is  cut  out 
over  that  part  of  the  back  where  the  ribs  were  depressed,  and 
allows  them  to  push  backward.  It  is  also  cut  far  enough  o^•er  the 
side  so  that  the  spine  may  overcorrect  laterally  still  farther.  On 
the  opposite  side,  in  front,  a  section  of  the  jacket  is  removed  to 
make  the  other  window.    This  allows  the  ribs  which  bulge  pos- 


'  As  the  details  ol  the  illustrations  may  be  confusing,  it  may  be  well  to  restate  the 
essentials  of  the  corrective  posture.  They  are  simply  to  place  the  patient  on  the 
back  in  a  sagging  hammock  and  to  increase  the  flexion  assured  by  the  weight  of 
the  body  by  elevating  the  legs.  The  shoulder  on  the  low  side  is  raised  and  drawn 
forward  by  the  arm.  while  the  other  shoulder  falls  backward  and  downward.  The 
pelvis  is  fixed  and  the  flexion  and  lateral  inclination  of  the  trunk  induced  bj-  the 
posture  are  further  increased  by  tension  straps.  It  is  verj-  doubtful  if  extreme 
force  in  correction  or  severe  pressure  afterward  is  even  desirable. 


TREATMENT  219 

teriorly  to  push  forward.  This  position  of  the  patient  is  neither 
esthetic  nor  comfortable  (Fig.  179),  yet  he  is  able  to  be  dressed 
and  can  easily  walk  about. 

"It  is  perhaps  needless  to  say  that  patients  while  undergoing  this 


Fig.   184. — Anterior  view  of  plaster  corset.    Slit  cut  through  plaster  for  the  insertion 
of  felt  pads  to  increase  the  flexion  of  the  spine. 


Fig.  185. — Posterior  view  of  plaster  corset  showing  windows.  When  the  body  is 
flexed  by  the  insertion  of  felt  pads  through  the  anterior  slit  in  Fig.  184,  the  bearing 
surfaces  over  the  bulging  ribs  and  over  the  lumbar  curve  prevent  these  parts  from 
moving,  but  all  other  parts  are  pushed  in  the  direction  of  overcorrection. 


220 


LATERAL  CURVATURE  OF   THE  SPINE 


treatment  do  better  if  confined  in  a  hospital,  where  the  necessarj^ 
care  can  be  given  them  and  they  will  be  under  constant  observation. 
"The  after-treatment  depends  entirely  upon  whether  the  over- 
correction is  accomplished  with  one  corset  or  whether  several  are 
used.  In  the  former  instance  it  is  necessary  to  place  pads  of  felt 
in  the  front  to  push  the  ribs  back  through  the  window  cut  behind, 
and  also  in  some  cases  to  put  pads  in  the  side  over  the  convexity 


Fig.  186. — Diagram  illustrating  the  changes  which  take  place  in  the  thoracic 
spine  when  felt  is  inserted  through  slits  in  Fig.  183.  The  same  changes  take  place 
in  the  lumbar  spine  by  this  procedure  but  they  are  not  so  marked.     (Abbott.) 

of  the  lateral  cm*ve.  When  the  corsets  are  first  applied  there  is 
firm  pressure  over  these  places,  but  in  a  few  days  the  change  in  the 
direction  of  overcorrection  is  so  rapid  that  it  is  possible  to  pass 
the  whole  hand  between  the  plaster  and  the  patient's  body  at  this 
point.  Xot  until  this  relaxation  takes  place  are  the  pads  used, 
and  then  only  of  such  a  thickness  as  will  not  cause  painful  pressure. 
This  procedure  is  repeated,  until  a  point  in  the  overcorrection  is 


TREATMENT  221 

reached  which  is  satisfactory;  when  this  is  attained  the  corset  is 
worn  until  the  parts  are  thoroughly  stretched  on  the  short  side, 
and  those  on  the  original  convex  side  have  had  time  to  shorten. 

"  In  all  the  patients  who  have  been  put  under  treatment  the  curve 
was  a  fixed  one,  and  in  those  cases  presented  the  spines  could  not 
be  straightened  by  muscular  effort  any  further  than  this  is  shown  in 
the  cuts  representing  the  original  deformities.  Many  of  the  patients 
had  been  under  treatment  for  years  (corsets,  braces,  and  exercises) 
with  very  little,  if  any  improvement. 

"  The  average  length  of  time  taken  to  produce  complete  overcor- 
rection was  three  weeks.  In  some  cases  ten  days  was  sufficient, 
while  in  others  it  was  necessary  to  continue  the  insertion  of  felt  for 
six  weeks.  The  amount  of  overcorrection  is  easy  of  determination, 
but  the  length  of  time  for  the  following  fixation  is  more  difficult 
to  estimate.  In  most  of  the  cases  mentioned  the  average  was  two 
months.  In  some  instances,  however,  the  period  of  fixation  was 
too  long,  making  it  hard  to  bring  the  spine  back  to  the  normal 
position  under  exercises.  This  was  especially  true  in  some  of  the 
easier  cases. 

"  In  reviewing  not  only  these  cases,  but  also  a  number  of  others, 
it  has  often  been  not  easy  to  determine  before  beginning  the 
treatment  what  kind  of  a  case  would  prove  the  most  difficult  to 
straighten.  Some  of  the  very  worst  deformities  yielded  far  more 
readily  than  the  lighter  ones.  There  are  three  factors  to  be  taken 
into  consideration:  The  age  of  the  patient,  and  the  length  of  time 
since  the  beginning  of  the  deformity;  the  size  and  shape  of  the 
body;  and  the  amount  of  flexion  which  can  be  made.  On  the  other 
hand,  it  is  frequently  easier  in  the  case  of  an  adult  patient  to  cor- 
rect a  deformity  of  some  years'  sta^nding  than  it  is  to  accomplish 
the  same  result  in  a  thick-set  child  where  the  curvature  is  of  recent 
development. 

"As  the  amount  of  rotation  and  its  correction  is  the  most  impor- 
tant part  of  the  deformity,  it  is  not  only  very  necessary  to  keep 
an  .T-ray  record  of  the  original  curve,  but  it  is  also  important  to 
make  frequent  skiagraphs  of  the  changes  which  follow.  If  care  is 
used,  the  exact  amount  of  rotation  at  any  time  may  be  determined, 
and  this  is  of  great  value  in  deciding  the  final  position  in  over- 
correction. The  treatment  of  a  case  after  the  corset  is  applied  is 
extremely  simple,  yet  it  is  best,  as  has  been  said  before,  to  confine 
the  patients  to  a  hospital  or  place  them  where  they  can  be  under 
close  observation.  They  should  be  allowed  to  walk  about  as 
much  as  possible,  not  only  for  the  exercise,  but  also  because  the 
body  weight  in  the  erect  position  aids  in  turning  the  spine. 

"  When  the  corset  is  finally  removed,  it  is  very  necessary  to  have 
the  patient  where  constant  treatment  by  exercises  and  massage 
may  be  carried  out.  It  is  desirable  in  nearly  all  cases  to  use  a 
light  brace  (or  celluloid  corset)  which  will  at  first  hold  the  spine  in 
an  overcorrected  position,  and  later  will  allow  it  to  come  gradually 


222  LATERAL   CURVATURE  OF   THE  SPIXE 

back  to  the  normal.  Unless  such  an  appliance  is  used,  the  deformity 
will  in  a  short  time  tend  to  reappear,  and,  like  club-foot,  turn  back 
into  its  original  position. 

"  The  general  condition  of  the  patients  after  the  deformity  has 
been  straightened,  has  been  of  much  interest.  Invariably  the 
health  has  improved,  and  many  have  gained  as  much  as  thirty 
pounds  in  weight.  One  of  the  most  striking  results,  especially  in 
adults,  is  the  increase  in  height;  in  some  of  the  severe  cases  this 
has  amounted  to  fully  three  inches.  The  gait  also  improves,  ^^^lat 
seems,  however,  to  be  of  far  more  importance  than  all  else  is  the 
change  in  their  mental  attitude.  Life  seems  to  present  a  very 
different  aspect  to  them,  showing  indubitably  that  a  deformed 
body  does  have  a  pronounced  effect  upon  the  mind. 

"  That  fixed  lateral  cm-vatm-e  of  the  spine  is  curable  by  the  method 
described  in  this  article  has  been  demonstrated.  As  the  cases 
treated  show,  it  has  passed  the  experimental  stage,  but  further 
experience  will  undoubtedly  produce  improved  technic  and  superior 
results.  The  term  '  curable'  is  used  here  to  mean  not  simply 
that  an  improvement  has  been  made  in  which  the  lateral  curve  is 
partially  obliterated  and  the  ribs  bent  to  a  different  angle,  but  that 
the  parts  entering  into  the  deformity  are  actually  turned  back  into 
their  normal  positions." 

The  paper  was  illustrated  by  more  than  SO  figures,  demonstrating 
the  progress  of  the  treatment  to  apparent  cm-e. 

It  has  been  abstracted  in  preference  to  later  articles  because  it 
presents  Dr.  Abbott's  views,  which  have  not  been  essentially 
changed  either  in  theory  or  practice  in  a  condensed  form. 

The  period  that  has  since  elapsed  has  been  one  of  disillusion- 
ment for  those  who  have  tested  the  treatment  on  a  large  scale. 
Dr.  Abbott,  judging  from  subsequent  articles,  modified  his  views 
as  to  the  ease  and  rapidity  with  which  cm-e  might  be  attained. 
The  original  correction  became  more  extreme,  the  padding  applied 
with  greater  pressure  and  the  duration  of  treatment  was  extended 
from  weeks  to  months,  or  years,  on  the  theory  apparently  that  the 
greater  the  resistance  the  greater  should  be  the  corrective  force 
and  the  more  persistant  its  application. 

It  would  appear,  however,  that  the  corrective  effect  of  the 
Abbott  treatment  is  accomplished  chiefly  by  posture  and  is  depend- 
ent therefore  on  the  flexibility  of  the  spine.  Forcible  distortion  of 
the  trunk,  however  extreme,  does  not  imply  overcorrection  of  the 
indi\'idual  segments  of  the  deformed  spine  without  which  ciu-e  is 
impossible.  In  most  instances  the  overcorrected  or  partly  corrected 
section  is  simply  displaced  laterally. 

Such  indirect  correction  if  maintained  for  a  sufficient  time  will 
improve  the  general  contom*  of  the  spine.  The  shape  of  the  thorax 
also  may  be  changed  somewhat  by  direct  pressure  and  by  the 
influence  of  respiration.  Wlien,  however,  the  constraint  is  removed, 
the  original  deformity  must  retiu'n  to  a  greater  or  less  degree 
because  the  correction  has  been  apparent  rather  than  actual. 


TREATMENT  223 

If,  then,  a  complete  cure  cannot  be  accomplished  in  a  definite 
time,  the  question  is  simply  whether  the  prospective  improvement 
is  worth  the  effort  required  to  attain  it,  a  question  of  especial 
importance  because  the  treatment  makes  its  strongest  appeal  to 
patients  with  advanced  deformity. 

The  disadvantages  of  the  treatment  are  a  grotesque  attitude  in 
which  the  chest  is  flattened  and  compressed  and  in  which  the  thoracic 
and  abdominal  organs  are  placed  at  a  great  functional  disadvantage. 

The  attitude  and  its  attendant  compression  cause  discomfort 
and  often  pain,  particularly  about  the  neck  and  elevated  shoulder. 
It  impedes  respiration  and  circulation.  The  pressure  of  the  pads 
on  the  front  of  the  chest  often  distorts  the  thorax  without  affecting 
the  curvature.  Pressure  sores  are  a  common  incident,  and  several 
deaths,  attributed  to  rupture  of  the  stomach  or  other  injury,  due 
to  violence  in  the  primary  application  of  the  treatment  have  been 
recorded. 

These  disadvantages  are  especially  apparent  when  contrasted 
with  treatment  by  jackets  applied  in  the  erect  posture  which 
improve  the  contour  of  the  trunk  and  the  appearance  of  the  patient 
during  this  period  of  attempted  correction. 

One  may  conclude  that  the  Abbott  theory  is  correct  and  that  the 
method  is  mechanically  the  most  effective  means  of  correcting 
lateral  curvature  of  the  spine,  but  that  its  effectiveness  is  strictly 
relative  to  the  duration,  the  character  and  the  resistance  of  the 
deformity,  and  that  confirmed  lateral  curvature  is  in  most  instances 
an  incurable  deformity. 

This  conclusion  is  supported  by  a  recent  report  of  the  Scoliosis 
Committee  of  the  American  Orthopedic  Association  in  which  no 
cure  of  fixed  scoliosis  in  the  anatomical  sense  by  any  method  of 
treatment  is  recorded.^ 

Dr.  Kleinberg,  of  the  staff  of  the  Hospital  for  Ruptured  and 
Crippled  who  has  had  an  extensive  practical  experience  with  the 
Abbott  method,  has  devised  a  brace  which  enforces  the  attitude 
of  anterolateral  flexion  and  supplies  pressure  by  means  of  tension 
bands.  This  permits  inspection,  lessens  the  danger  of  pressure 
sores  and  is  apparently  nearly  as  effective  as  the  plaster  jacket  and 
padding. 

When  the  deformity  is  dependent  upon  irremediable  injury  or 
disease,  such,  for  example,  as  anterior  poliomyelitis  or  empyema, 
some  form  of  brace  must  be  employed  habitually  to  prevent 
excessive  lateral  deviation  of  the  trunk;  and  in  cases  of  fixed  deform- 
ity in  older  subjects,  especially  if  the  patient's  occupation  is  fatigu- 
ing, a  support  may  be  indicated  to  relieve  symptoms  of  discomfort 
or  pain. 

Support  is  employed  primarily  with  the  aim  of  preventing  an 
increase  of  deformity  and  to  relieve  symptoms  incidental  to  it. 

'  Dr.  Abbott's  latest  and  most  complete  exposition  of  the  treatment  may  be  found 
in  successive  numbers  of  the  Journal  of  the  American  Orthopedic  Association, 
January  to  June,   1917. 


224  LATERAL  CURVATURE  OF   THE  SPINE 

It  may  serve,  also,  in  some  degree  as  a  corrective  appliance.  If  it 
holds  the  spine  in  the  extended  position  or  induces  lordosis,  it  may, 
by  relieving  the  anterior  portion  of  the  column  in  part  from  the 
deforming  influence  of  superincumbent  weight,  induce  or  permit  a 
slight  lessening  of  the  rotation  of  the  vertebral  bodies.  On  this 
principle  a  light  steel  brace,  after  the  Taylor  model,  may  be  as 
effective  as  any  of  the  more  complicated  appliances,  as  was  sug- 
gested many  years  ago  by  Judson.  Corsets  of  other  material  than 
plaster,  for  example,  of  paper,  celluloid  or  of  aluminum,  as  suggested 
by  Phelps,  may  be  employed  when  the  deformity  is  fixed  and  when 
no  change  in  the  position  or  size  of  the  trunk  is  to  be  expected. 
The  Knight  brace,  when  carefully  adjusted,  appears  to  meet  the 


Fig.  187. — The  Knight  spinal  brace,  as  used  in  lateral  curvature.  A  leather  or 
canvas  band,  made  adjustable  by  lacings,  is  stretched  from  the  posterior  upright  to 
the  side  bar  on  the  side  of  the  dorsal  convexity. 

requirements  fairly  well,  and  when  less  support  is  needed  an  ordi- 
nary corset  strengthened  by  light  steels  may  be  sufficient.  Even 
in  cases  of  this  character  corrective  exercises  should  be  employed 
with  the  aim  of  preserving  as  far  as  possible  the  flexibility  of  the 
spine. 

Supplemental  Treatment. — The  Removal  of  Superincumbent 
Weight. — The  removal  of  superincumbent  weight  by  the  assump- 
tion of  the  reclining  posture  whenever  the  patient  is  fatigued  is  an 
important  adjunct  in  the  treatment.  The  patient  should  lie,  pref- 
erably, upon  a  hard  support  in  the  supine  posture,  with  the  arms 
extended  above  the  head.  If  the  dorsal  kyphosis  is  exaggerated, 
a  firm  cushion  between  the  shoulders  or  under  the  projecting  ribs 
will  aid  to  expansion  of  the  chest  and  favor  the  correction  of  the 
deformity. 


TREATMENT 


225 


Self-suspension. — Self-suspension,  by  means  of  the  halter  and 
pulley,  is  of  service  in  overcoming  secondary  contractions  of  the 
tissues,  and  thus  aiding  in  the  correction  of  deformity.  It  is  often 
efficacious  also,  in  relieving  the  discomfort  that  is  sometimes  a 


Fig.  188. — Congenital  scoliosis.  After  treatment  for  three  years  by  forcible  correc- 
tion and  fixation  by  plaster  jackets.  Showing  the  disappearance  of  the  rotation. 
(Franke].) 


Fig.  189. 


-Applied  for  left  lumbar 
scoliosis. 


Fig.  190.- 


-Right  curve,  dorsal 
scoliosis. 


troublesome  symptom  when  the  distortion  is  extreme.  While  the 
patient  is  suspended,  forcible  manual  correction  of  the  deformity 
may  be  applied  to  advantage. 

Suspension  from  the  horizontal  bar  has  a  similar  effect,  although 
it  is  less  effective  than  when  the  traction  is  made  upon  the  entire 
15 


226 


LATERAL  CURVATURE  OF   THE  SPIXE 


spine.  In  this  form  of  suspension  the  bar  should  be  oblique  in 
direction,  the  high  side  for  the  low  shoulder.  Thus,  a  passive 
''key-note"  is  induced  while  the  patient  is  suspended.  Exercises 
in  this  position,  for  example,  flexion,  extension,  and  abduction  of 


Fig.  191  Fig.  192 

Figs.   191  and  192. — Self-suspension,  illustrating  the  effect  of  traction  in  lessening 

deformity  induced  by  paralj-sis.      (Gibney.)     In  such  cases  support  is  essential. 


the  thighs,  swaying  the  trunk  from  side  to  side,  ''chinning"  the 
bar,  and  the  like,  are  useful. 

Volkmann  Seat. — In  cases  of  prunary  lumbar  curvature,  or  when 
the  secondary  cur\-e  of  this  region  is  pronounced,  the  attitude 
may  be  improved  and  the  deformity  may  be  corrected  in  part  by 


TREATMENT  227 

seating  the  patient  on  an  inclined  plane,  the  high  side  beneath  the 
low  hip,  thus  lessening  the  convexity  of  the  curve. 

High  Shoe. — The  same  object  may  be  attained  in  the  erect  pos- 
ture by  the  use  of  a  higher  heel,  or  heel  and  sole.  The  elevation 
may  be  from  a  half-inch  to  an  inch  and  a  quarter,  the  amount 
being  regulated  by  its  effect  upon  the  contour  of  the  trunk. 

Support  during  Recumbency. — If  a  corrective  corset  is  used  it 
may  be  worn  with  advantage  at  night — or  a  plaster  bed  corre- 
sponding to  the  posterior  half  of  a  jacket  may  be  constructed. 
This  is  suitably  padded  and  is  fixed  to  crossbars.  In  this  the 
patient  lies  at  night,  deformity  being  prevented  and  a  certain 
corrective  force  is  also  exerted.  This  support,  according  to  Jaeger, 
is  not  only  tolerable  but  is  more  comfortable  in  cases  of  advanced 
deformity  than  is  the  ordinary  bed. 

General  Treatment. — The  importance  of  improving  the  gen- 
eral condition  of  the  patient  by  regulation  of  the  diet,  by  cold 
baths,  and  by  active  exercise  in  the  open  air  is  self-evident.  The 
strain  upon  the  back  should  be  lessened  by  providing  proper  seats 
and  by  limiting  the  time  passed  in  passive  attitudes,  and  by  less- 
ening, as  far  as  possible,  the  restraint  of  the  clothing.  These 
precautions  are  of  almost  equal  importance  with  the  active 
treatment 

The  Duration  of  Treatment. — The  duration  of  treatment  depends, 
of  course,  upon  the  character  of  the  deformity  and  upon  its  causes. 
In  the  ordinary  type  of  adolescent  scoliosis  the  duration  of  active 
treatment  is  usually  from  three  to  six  months.  In  this  time  the 
muscles  may  be  so  strengthened  and  the  necessity  for  constant 
attention  to  the  attitudes  may  be  so  impressed  upon  the  patient 
that  the  simple  exercises  which  may  be  performed  at  home  may  be 
sufficient.  In  such  exercises  the  most  important  postures  are  those 
which  hyperextend  the  spine.  The  constant  effort  should  be  to 
make  motion  in  one  direction  as  free  as  in  another,  and  to  practise 
postures  that  tend  to  reduce  deformity.  In  all  cases  it  is  well,  if 
possible,  to  keep  the  patient  under  supervision  during  the  period 
of  growth. 

In  reviewing  the  treatment  it  would  appear  that  gymnastic 
treatment  is  most  efficient  as  a  preventive.  That  it  is  curative 
only  in  the  preliminary  or  potential  stage  of  the  deformity.  That 
it  is  of  value  when  properly  conducted  at  any  stage,  as  a  means 
of  improving  the  posture,  of  relieving  discomfort  and  for  its  general 
effect  on  the  condition  of  the  patient. 

That  the  Abbott  method  is  most  effective  from  the  mechanical 
stand-point  and  is  indicated  in  those  cases  in  which  the  deformity 
may  be  overcome  in  a  definite  period. 

That  the  great  majority  of  cases  in  adolescent  and  adult  life 
are  incurable,  although  susceptible  in  most  cases  of  improvement, 
and  that  treatment  should  be  undertaken  with  an  understanding 
of  its  limitations. 


CHAPTER   IV. 

DEFORMITIES  OF   THE   SPINE   (Continued).    DEFORM- 
ITIES OF  THE  CHEST.     THE  FUXCTIOXAL 
PATHOGENESIS  OF  DEFORMITY. 

VARIATIONS   IN  THE  CONTOUR  OF  THE  SPINE. 

One  recognizes  a  certain  contour  of  the  spine  as  normal,  but 
there  are  variations  from  this  type  which,  within  certain  hmits, 


Fig.   193. — The  hollow  round  back. 
(Stafel.) 


Fig.  194. 


-The     round     back. 
(Stafel.) 


can  hardly  be  classed  as  abnormal.     Two  of  these  have  been  men- 
tioned: the  round  back  (Fig.  194),  in  which  there  is  a  general  forward 


ANTEROPOSTERIOR  DEFORMITIES  OF   THE  SPINE      229 

droop  most  marked  at  the  shoulders,  and  the  hollow  round  hack 
(Fig.  193),  in  which  the  dorsal  kyphosis  and  the  lumbar  lordosis 
are  somewhat  exaggerated.  A  third  type  is  the  flat  back  (Fig.  101), 
in  which  there  is  neither  a  lumbar  lordosis  nor  a  dorsal  kyphosis. 
In  the  marked  cases  there  is  an  actual  prominence  in  the  lumbar 
region,  while  the  scapulse  project  backward,  overhanging  the  flat- 
tened dorsal  spine.  This  type  of  back  may  be  the  result  of  a  rhachi- 
tic  kyphosis  which  was  most  prominent  in  the  lumbar  region,  and  it 
often  follows  a  primary  lateral  rotation  of  the  lumbar  vertebrae. 
The  flat  back  and  the  round  back  predispose  to  lateral  curvature. 
Deviations  from  the  normal  contour  of  the  spine  are  attended  by 
a  change  in  the  inclination  of  the  pelvis  and  in  the  relation  of  the 
support  of  the  limbs  and  trunk.  The  round  back  (Fig.  194)  is 
almost  always  indicative  of  weakness,  and  it  is  often  accompanied 
by  other  postural  deformities,  especially  often  by  weak  feet. 

ANTEROPOSTERIOR  DEFORMITIES  OF  THE  SPINE. 

Kyphosis. — ^As  has  been  stated  in  the  chapter  on  Pott's  Dis- 
ease, the  spine  is  practically  straight  at  birth.  If  during  the  early 
weeks  of  life  an  infant  be  placed  in  the  sitting  posture  the  head  falls 
forward  and  the  spine  bends  into  a  long  posterior  curve,  the  posture 
of  weakness.  The  normal  anterior  convexity  of  the  cervical  section 
is  established  when  the  gain  in  muscular  power  enables  the  infant 
to  hold  the  head  erect,  and  that  of  the  lumbar  region  when  the  pelvis 
is  tilted  downward  by  the  extension  of  the  thighs  in  the  erect  posture. 

In  the  erect  posture  the  constant  tendency  of  the  weight  of  the 
head  and  of  the  thoracic  and  abdominal  organs  is  to  draw  the  spine 
forward.  This  tendency  is  resisted  by  the  action  of  the  posteror 
muscles  of  the  trunk.  Whenever,  therefore,  the  muscular  power  is 
lessened  or  the  body  is  overburdened,  or  whenever  the  spine  is 
weakened  by  disease,  the  tendency  toward  the  original  curve  of 
weakness  becomes  apparent  (Fig.  194).  Thus  the  causes  of  an 
abnormal  increase  in  the  posterior  curvature  of  the  spine  are  very 
numerous.  It  is,  as  has  been  stated,  the  characteristic  attitude  of 
weakness,  as  is  illustrated  in  infancy  and  in  old  age.  It  is  one  of  the 
common  occupation  deformities  of  adult  life;  it  is  a  common  pos- 
tural deformity  of  childhood  and  adolescence.  It  may  be  induced 
by  a  variety  of  diseases  that  lessen  the  resistance  of  the  spine  or  that 
interfere  with  its  function.  For  example,  by  rhachitis,  spondylitis 
deformans,  osteitis  deformans.  Pott's  disease,  and  affections  of  a 
similar  nature. 

The  kyphosis  of  rhachitis  is  most  marked  in  the  lower  region,  that 
of  spondylitis  deformans  may  involve  the  entire  spine,  while  the 
simple  postural  curvature  is  most  marked  in  the  upper  dorsal  region 
— "round  shoulders."  In  a  number  of  the  postural  deformities  the 
increase  in  the  dorsal  kyphosis  is  balanced  by  an  increased  lordosis. 


230 


DEFORMITIES  OF   THE  SPIXE 


and  in  this  form  there  is  simply  an  exaggeration  of  the  normal  curves 
of  the  spine — the  "hollow  round"  back.  In  other  instances  there 
is  a  general  forward  droop  of  the  trmik  in  which  the  lumbar  lordosis 
may  be  lessened:  this  form  is  more  common  in  childhood — ^the 
"round"  back. 

The  forms  of  k^-phosis  that  are  the  du-ect  result  of  disease  have 
been  described  elsewhere.  Postural  kyphosis — "round  shoulders" 
— is  one  of  the  common  deformities,  and  in  childhood  its  etiology  is 
similar  to  that  of  lateral  curvature,  of  which  it  may  be  a  predispos- 


FiG.   195. — Marked  posterior  ciirvature  of  the  spine  apparentlj-  induced  by  weakness 

incidental  to  illness. 


ing  cause.  Roimd  shoulders  and  the  accompanying  so-called  flat, 
but  in  reality  narrow  and  therefore  deeper,  chest  may  be  induced 
also  by  obstructions  in  the  respiratory  passages,  such  as  enlarged 
tonsils,  adenoids,  and  the  like,  or  by  bronchitis  or  heart  disease. 
Another  predisposing  cause  is  clothing  that  prevents  the  full  ex- 
pansion of  the  chest  and  the  extension  of  the  arms,  and  even  the 
weight  of  clothing  suspended  from  the  shotilders  may  be  a  factor  in 
the  etiology.  These  and  other  possible  contributing  causes  shotild 
be  investigated  in  all  cases  of  this  character. 


ANTEROPOSTERIOR  DEFORMITIES  OF   THE  SPJNE      23l 

A  more  extreme  type  of  deformity  is  sometimes  seen  in  adolescents 
(Fig.  196),  induced  apparently  by  posture  and  by  overwork,  al- 
though in  most  instances  it  may  be  assumed  that  a  slighter  deform- 
ity of  long  standing  has  served  as  a  predisposing  cause.  In  this  type 
the  deformity  is  resistant,  and  is  accompanied  by  adaptive  changes 
in  the  vertebrae  that  prevent  complete  correction. 

Symptoms. — The  most  important  symptom  is  the  deformity  itself. 
In  adolescent  cases  there  is  often  some  discomfort  of  the  nature  of 
strain  and  tir^  usually  referred  to  the  scapular  region  but  in  the  rigid 
type  the  pain  is  most  marked  below  the  projection. 


Fig.   196. — Posterior   curvature   of   the   spine   in    adolescence   witli   rigidity. 
A  deformity  that  may  be  mistaken  for  that  of  spondylitis  deformans. 

Treatment. — Even  slight  posterior  curvatures  of  the  spine  check 
the  expansion  of  the  chest  and  disturb  the  balance  of  the  body. 
Furthermore,  as  it  has  been  demonstrated  by  .i--ray  pictures  that 
the  internal  viscera  may  be  lifted  from  three  to  six  inches  by  mus- 
cular effort  in  the  erect  posture,  it  is  apparent  that  serious  and  per- 
manent displacement  of  these  organs  may  result  from  habitual 
deformity.  Consequently  the  maintenance  of  the  erect  posture 
from  childhood  to  old  age  is  of  the  greatest  importance. 

The  treatment  is  similar  to  that  of  lateral  curvature.  The 
assumption  of  the  military  attitude,  with  the  head  erect,  the  chin 
depressed,  the  shoulders  thrown  back,  the  chest  expanded,  and  the 
abdomen  retracted,  should  be  encouraged.     And  those  exercises 


232 


DEFORMITIES  OF   THE  SPINE 


that  expand  the  chest  and  that  strengthen  the  muscles  of  the  upper 
part  of  the  spme  are  especially  important.  (Such  exercises  are 
illustrated  by  Figs.  125,  126,  132,  133,  144,  145,  146,  147,  149,  152, 
163  and  164).  If  the  range  of  vertical  extension  of  the  arms  is 
limited,  this  restriction  must  be  overcome  before  the  deformity  of 
the  spine  can  be  permanently  improved.  In  well-marked  cases  the 
patient  should  be  encouraged  to  read  or  study  in  the  prone  posture. 
In  this  attitude,  in  which  the  trunk  must  be  supported  upon  the 


Fig.  197  Fig.  198 

Figs.  197  and  198. — Exercises  for  the  correction  of  posterior  curvatures  of  the  spine. 

(Hoffa.) 


elbows  and  the  head  held  backward,  there  is  necessarily  an  involun- 
tary correction  of  the  deformity.  In  certain  instances  a  light  spinal 
brace  or  corset  may  be  employed  during  the  hours  when  the  passive 
attitude  must  be  assumed  (Fig.  199).  Shoulder  braces,  so-called, 
are  useless,  because  the  lumbar  lordosis  is  increased  when  the 
shoulders  are  drawn  backward.  Clothing  should  not  restrict  the 
movements  of  the  arms  or  trunk,  and  as  little  weight  as  possible 
should  be  suspended  from  the  shoulders.  In  the  more  extreme 
cases  a  Calot  jacket  should  be  applied  as  described  in  the  chapter 
on  Pott's  Disease.     If  the  k^^)hosis  is  of  long  duration  and  rigid. 


ANTEROPOSTERIOR  DEFORMITIES  OF   THE  SPINE      233 

as  in  adolescent  cases,  forcible  manipulation  under  anesthesia  may 
be  of  service  before  applying  the  support.  Afterward  treatment 
by  manipulation,  exercise  and  posture  is  continued  as  in  cases  of  the 
ordinary  type.  Whenever  a  patient  is  under  treatment  for  deform- 
ity of  the  trunk  the  attempt  should  be  made  to  restore  the  proper 
relation  of  the  body  and  limbs,  and  thus  to  restore  the  general  sym- 
metry of  the  body.  Attention  is  again  called  to  weak  feet  as  the 
most  common  and  important  accompaniment  and  predisposing 
cause  of  deformities  of  this  class. 


Fig.  199. — A  brace  for  round  shoulders.     (Goldthwait.) 


Lordosis  .^ — ^Lordosis,  or  an  abnormal  hollo wness  of  the  back, 
is  far  less  common  than  kyphosis.  It  is  usually  secondary  to  disease 
or  deformity  either  of  the  spine  or  of  the  lower  limbs.  For  example, 
lordosis  may  be  induced  by  flexion  contraction  of  the  thighs;  it  is 
a  symptom  of  congenital  displacement  of  the  hips;  it  is  sometimes 
a  result  of  certain  forms  of  nervous  disease,  in  which,  because  of 
muscular  weakness,  the  body  is  swayed  backward  to  retain  the 
balance,  as  in  the  muscular  dystrophies.  Lordosis  in  the  lumbar 
region  may  be  a  compensation  for  a  kyphosis  in  the  upper  segment. 
It  is  caused  directly  by  spondylolisthesis.  It  may  be  a  congenital 
deformity;  it  is  said  to  be  a  peculiarity  of  contortionists  and  in  a 
mild  degree  it  may  be  induced  by  the  habitual  use  of  high  heels. 

Treatment. — ^As  lordosis  is  usually  a  secondary  d'jformity  its 
treatment  would  be  included  in  the  treatment  of  its  causes.  In 
some  instances  the  discomfort  which  is  usually  present  when  the 
deformity  is  well  marked  may  be  relieved  by  a  proper  corset  suf- 
ficiently strong  to  support  the  back. 


234  DEFORMITIES  OF  THE  SPINE 

CONGENITAL  ELEVATION  OF  THE  SCAPULA. 

Synonym. — Sprengel's  Deformity. — Sprengel's  deformity  is  a  con- 
genital elevation  of  the  scapula  above  the  level  of  its  fellow,  an 
elevation  accompanied  in  most  instances  by  rotation,  so  that  its 
lowei"  angle  is  brought  nearer  to  the  spine  while  its  upper  border 
projecting  and  bent  forward  above  the  clavicle  has  in  several 
instances  been  mistaken  for  an  exostosis  (Fig.  200).  The  cervical 
muscles  passing  to  the  scapula  are  shortened  and  changed  in 
direction  and  in  about  25  per  cent,  of  the  cases  the  median 
border  of  the  scapula  is  attached  to  one  of  the  lower  cervical 
vertebrae  by  a  bony  prolongation  which  may  be  an  outgrowth 
from  a  transverse  process  or  jointed  at  either  extremity.  Thus,  its 
mobility  is  lessened  and  the  range  of  vertical  extension  of  the  arm 
is  restricted.     The  deformity  may  be  combined  with  torticollis  or 


^Hr 

I'driHP^ 

IMm. 

/' 

Fig.  200. — Congenital  elevation  of  the  left  scapula;  with  the  arm  elevated  the 
scapula  is  in  contact  with  the  occiput,  as  is  indicated  by  the  deep  fold;  age  of  the 
p.atient  three  months. 

with  cervical  ribs  or  defective  formation  of  the  spine,  for  example, 
absence  of  vertebrae  or  rhachischisis.  In  many  instances  there  is 
an  accompanying  lateral  curvature  of  the  spine,  the  convexity  being 
usually  toward  the  deformed  side.  Ninety-nine  cases  have  been 
collected  from  literature  by  Zesas.^  Forty-seven  were  of  the  right 
side,  36  of  the  left,  and  in  11  both  scapulae  were  elevated.  Of  82 
cases  48  were  in  males.  The  most  recent  and  complete  review  of 
the  subject  is  by  A.  E.  Horwitz^  of  136  cases.  Scoliosis  was  present 
in  47  per  cent.,  torticollis  in  10  per  cent.,  and  asymmetry  of  the 
skull  and  face  without  torticollis  in  11  per  cent.  In  67  per  cent, 
there  was  some  accompanying  defect  in  formation.'^ 

1  Ztschr.  orth.  Chir.,  1905,  Band  xv,  Heft  1. 

2  Am.  Jour,  orthop.  Surg.,  1909,  vi.  No.  2. 

3  The  deformity  was  first  described  by  Eulenburg  (Arch.  f.  klin.  Chir.,  1868),  but 
in  more  detail  by  Sprengel  (Centralbl.  f.  Chir.,  1895),  who  reported  4  cases  in 
children  from  one  to  seven  years  of  age. 


CONGENITAL  ELEVATION  OF  THE  SCAPULA 


235 


Etiology. — The  etiology  is  doubtful,  but  in  many  instances  it 
appears  to  be  the  result  of  a  constrained  position  of  the  fetus.  In 
2  of  Sprengel's  cases,  seen  soon  after  birth,  the  arm  appeared  to 
have  been  fixed  behind  the  back  of  the  child. 

It  is  of  interest  to  note  that,  according  to  Chievitz,  the  upper 
limb  is  in  its  origin  a  cervical  appendage,  retaining  an  elevated 
position  during  fetal  life,  and  that  interference  with  its  descent  by 
constraint  or  otherwise  may  explain  the  etiology.  In  some  in- 
stances the  influence  of  heredity  is  marked,  the  deformity  appearing 
in  several  generations,  and  in  such  cases  the  shape  of  the  scapular 
appears  to  indicate  a  reversion  to  a  lower  type.'^ 


Fig.  201. — Congenital  elevation  of  the  scapula  of  a  moderate  degree  in  adolescence. 


Congenital  elevation  of  the  scapula  may  be  simulated  by  the 
distortion  and  muscular  atrophy  resulting  from  birth  palsy,  or  even 
by  certain  cases  of  rotary  lateral  curvature  in  which  the  scapula  is 
elevated  and  prominent. 

In  suitable  cases  all  the  shortened  tissues  should  be  divided 
through  an  open  incision,  the  bony  attachment  to  the  scapula 

1  Neuhoff:  Am.   Jour.   Dis.   Children,   May,   1914. 


236  DEFORMITIES  OF   THE  SPINE 

removed  and  the  deformity  should  be  as  far  as  possible  corrected 
b}'  force.  A  fixation  support  of  plaster  of  Paris  is  then  applied. 
Supplemental  treatment  by  forcible  stretching  is  afterward 
employed,  as  in  the  treatment  of  torticollis. 


DEnCIENCY  AND  MALFORMATION  OF  VERTEBRA. 

Absence  of  vertebrse  is  often  associated  with  rhachischisis. 
Several  cases,  however,  have  come  under  my  observation  in  which 
there  w^as  absence  of  vertebree  w'ithout  other  malformation.  In 
2  of  the  cases  the  deficiency  was  in  the  cervical  region,  in  the 
others  in  the  lumbar.  The  noticeable  shortness  of  the  affected  sec- 
tion of  the  spine  was  the  only  s\Tnptom.  Supernumerary  and  other- 
wise malformed  vertebrae  have  recently  been  demonstrated  by  x-ray 
examinations  to  be  a  more  important  factor  in  the  etiology  of  de- 
formity of  the  spine  than  had  been  suspected  formerly. 


ABNORMALITIES  OF  RIBS. 

Cervical  Ribs. — Cervical  ribs  are  not  uncommon.  They  may 
be  divided  into  fom*  classes: 

1.  x4n  increase  of  the  costal  process  not  reaching  beyond  the  trans- 
verse process. 

2.  Extending  beyond  the  transverse  process,  terminating  in  a 
free  end  or  united  to  the  first  rib. 

3.  Longer,  attached  to  the  first  rib  by  a  ligament. 

4.  Complete  ribs. 

In  most  instances  the  anomaly  is  bilateral  but  more  developed 
on  one  than  on  the  other  side. 

If  the  rib  is  unilateral  it  is  often  connected  with  a  defective 
supernumerary  vertebra.  In  such  instances  the  spine  is  often 
deflected  to  form  a  lateral  ciu-vature  toward  the  abnormalit^^ 

If  the  ribs  are  complete  the  neck  appears  wide  and  short  and  the 
projecting  ribs  may  be  felt  as  bony  prominences  (Fig.  202).  Of  161 
recorded  cases  114  were  in  females.^ 

The  subject  is  of  siu-gical  interest  because  a  number  of  cases 
have  been  reported  in  which  pressure  on  the  nerves  and  blood- 
vessels induced  pain  and  even  paresis  of  the  arm  and  feeble  circu- 
lation. Such  sATiiptoms,  as  a  rule,  do  not  appear  until  adolescence 
or  adult  life.  The  treatment  is  resection  of  that  portion  of  the  rib 
that  causes  pressure."'^  In  these  cases  the  artery  is  usually  above 
and  the  vein  below  the  rib.^ 


1  Streisler:  Ergab.  d.  Chir.  u.  Orthop.,  1913,  Band  iv. 
-  Roberts:  Jour.  Am.  Med.  Assn.,  October  3,  1908. 
3  Henderson:  Am.  Jour.  Orthop.  Surg.,  April,  1914. 


ABNORMALITIES  OF  RIBS 


237 


Absence  of  Ribs. — Absence  or  defective  formation  of  ribs  is 
uncommon.     In  such  cases  there  is  usually  defective  formation  of 


the  corresponding  muscles,  and  lateral  curvature  of  the  spine  is 
often  present.     (See  Congenital  Lateral  Curvature.) 


238  DEFORMITIES  OF   THE  CHEST 

MALFORMATION  OF  PECTORAL  MUSCLES. 

Several  instances  in  which  one  or  both  of  the  pectoral  muscles 
were  defective  or  absent  have  been  observed  at  the  Hospital  for 
Ruptured  and  Crippled.  The  malformation  in  these  cases  caused 
no  direct  symptoms.^ 

ABNORMALITY  OF  CLAVICLE. 

Thirty-eight  cases  of  defective  formation  of  the  clavicle  on  one 
or  both  sides  are  recorded.^  Of  27  cases  reported  by  Heinecke^  the 
defect  was  bilateral  in  20.  In  most  instances  a  portion  of  the  sternal 
extremity  is  present.  The  defect  appears  to  cause  but  slight  incon- 
venience. 

DEFORMITIES  OF  THE  CHEST. 

Flat  Chest. — The  so-called  flat  chest  is  an  accompaniment  of 
the  round  back  (Fig.  194).  The  shoulders  and  scapulae  being  dis- 
placed forward  the  chest  becomes  less  prominent. 

^Yoods  Hutchinson  has  called  attention  to  the  fact  that  the  so- 
called  flat  chest  is  in  reality  a  round  chest,  in  the  sense  that  the 
thorax  Is  actually  deeper  than  the  normal,  a  persistence  of  the  fetal 
t^'pe.  He  suggests  that  such  persistence  may  be  one  of  the  causes 
of  round  shoulders,  the  round  chest  aft'ording  no  adequate  support 
for  the  scapulae. 

Hutchinson^  has  presented  an  mdex  showing  the  relative  depth 
of  the  chest  at  different  ages,  illustrating  the  progress  from  the  keel 
chest  of  the  lower  orders  to  the  bellows  shape  of  the  adult  human 
form.  This  index  is  found  by  dividing  the  anteroposterior  diameter 
at  the  nipples  by  the  transverse  diameter  at  the  same  level;  hence 
the  lower  the  index,  the  longer  and  flatter,  more  bellows-like  the 
chest. 

Embn^o 105-115 

At  birth 101 

Under  2  years 94 

3  to  7  years 85 

14  to  18  years 80 

Adult 72 

Treatment. — The  treatment  of  the  so-called  flat  chest  is  similar 
to  that  of  the  round  shoulders,  with  which  it  is  combined — that  is, 
by  exercises  conducted  ^ith  the  special  object  of  improving  the 
strength  of  the  muscles  of  the  back  and  increasing  the  expansion 
of  the  upper  part  of  the  chest.  The  unportance  of  correcting  the 
deformity,  which  interferes  with  the  proper  expansion  of  the  lungs 
and  thus  predisposes  to  disease,  should  be  evident. 

1  Martirene:  Rev.  d'Orthop.,  May,  1903. 

2  Klar:  Ztsehr.  f.  orthop.  Chir.,  1906,  Band  xv,  Heft  2. 

3  Ztsehr.  f.  orthop.  Chir.,  1908,  Band  xsi.  Heft  4. 

^  Jour.  Am.  Med.  Assn.,  September  11,  1897,  and  May  2,  1903. 


FUNNEL  CHEST 


239 


Pigeon  Chest. — Synonym. — Pectus  carinatum. 

The  pigeon,  or  keel-shaped,  chest  resembles  the  quadrupedal 
type  m  that  the  anteroposterior  is  increased  at  the  expense  of  the 
lateral  diameter.  The  sternum  is  thrust  forward  and  downward 
like  the  keel  of  a  boat,  the  lateral  compression  being  most  marked 
at  the  junction  of  the  ribs  and  the  cartilages.  This  deformity  is 
almost  always  acquired  (Fig.  203) ;  it  is  usually  an  effect  of  rhachitis, 
and  it  is  described  under  that  heading.  It  may  be  induced  by  ob- 
struction of  respiration  caused  by  enlarged  tonsils  and  the  like,  if 
this  is  present  at  an  early  age.  It  may  be  a  secondary  effect  of 
the  sinking  forward  and  downward  of  the  upper  half  of  the  trunk, 
as  in  Pott's  disease. 


Fig.  203. — General  rhachitic  distortions  and  pigeon  chest. 


Treatment. — The  treatment  of  secondary  deformity  would  be 
included  in  the  treatment  of  the  affection  of  which  it  is  the  result. 
Manipulation,  massage,  and  breathing  exercises  may  be  employed 
in  the  treatment  of  simple  pigeon  chest.  The  tendency  is  toward 
spontaneous  cure;  it  is  rarely  seen  in  adult  life. 

Funnel  Chest. — Synonym, — Pectus  excavatum. 


240     ACQUIRED  LUXATION  OR  SUBLUXATION    OF    CLAVICLE 

This  deformity  (Fig.  204)  is  the  reverse  of  the  pigeon  chest.  The 
sternmn  is  depressed  and  the  lateral  diameter  of  the  thorax  is  cor- 
respondingly increased.  The  milder  types  of  the  affection  in  which 
there  are  one  or  more  depressions  or  hollows  in  the  sternmn  are 
common.  The  extreme  form,  in  which  the  entire  sternum  is  de- 
pressed, is  rare.  It  is  practically 
always  a  congenital  deformity, 
and  it  is  not  susceptible  to  direct 
treatment. 

Minor  Deformities  of  the 
Chest. — As  has  been  stated,  dis- 
tortions of  the  chest  secondary 
to  deformity  of  the  spine  are 
often  discovered  before  the  orig- 
inal cause  is  suspected.  And 
the  importance  of  the  various 
minor  irregularities  of  the  chest 
or  in  the  direction  of  the  ribs 
when  once  discovered  is  often 
exaggerated.  They  are  usually 
the  result  of  preceding  rhachitis. 
The  increase  of  the  capacit}^  of 
the  chest  by  appropriate  exer- 
cises aids  in  the  correction  of 
asjTimietry. 

SCAPULAR  CREPITUS. 

Creaking  or  grating  sounds 
induced  by  certain  movements 
of  the  scapula  on  the  thorax 
sometimes  appear  without  ap- 
parent cause  or  are  developed 
by  exercises  during  the  treat- 
ment of  lateral  cm-vatiu-e.  In 
some  instances  bony  irregularities,  bursse,  and  the  like  may  be 
present.  Twenty-two  cases  are  reported  by  Kuttner,^  and  de  Laro- 
quette  found  scapular  crepitus  in  8.2  per  cent,  of  620  healthy  indi- 
viduals. 


Fig.  204. — Pectus  excavatum.     This 
patient  has  ocular  torticollis  also. 


ACQXnRED    LUXATION    OR    SUBLUXATION  OF    THE   CLAVICLE. 

Partial  displacement  of  the  sternal  end  of  the  clavicle  is  not  par- 
ticularly uncommon.  In  some  instances  it  is  caused  by  injury;  in 
others  no  cause  can  be  assigned.  ]\Iost  often  there  appears  to  be  a 
laxity  of  the  capsular  ligament  that  permits  a  displacement  diuing 

1  Deutsch.  med.  Wchnschr.,  June  23,  1904. 


ASYMMETRICAL  DEVELOPMENT 


241 


certain  movements  of  the  arm.  The  displacement  is  readily  re- 
duced, but  the  weakness  and  insecurity  may  cause  discomfort  and 
disability. 

Treatment. — In  some  instances  the  displacement  may  be  pre- 
vented by  the  pressure  of  a  pad  and  truss  spring,  attached  behind 
to  the  corset  or  braces  and  passing  over  the  shoulder  close  to  the 
neck.  Such  an  appliance  is  especially  useful  if  the  displacement 
occurs  at  certain  times  only,  as  in  dressing  the  hair,  playing  on  the 
violin,  etc.*  Cures  are  reported  as  the  result  of  the  injection  of 
alcohol  into  the  joint  from  time  to  time,  and  Wolffs  has  operated 
with  success  as  follows:  The  joint  is  opened  by  a  straight  incision. 
A  fragment  of  bone  is  detached  from  the  clavicle  above  and  a  similar 
one  from  the  sternum;  these,  still  adherent  to  the  periosteum,  are 
overlapped  in  front  of  the  joint  and  the  capsule  is  then  sutured.  As 
a  rule  the  affection  is  not  of  particular  importance. 


Fig.  205. — Hypertrophy  of  the  right  forearm  and  hand,  due  to  congenital  nevus. 


ASYMMETRICAL  DEVELOPMENT. 

In  normal  individuals  there  is  often  a  slight  difference  between 
the  two  halves  of  the  body,  and,  as  is  well  known,  inequality  in  the 

I  Centralbl.  f.   Chir.,   November  30,   1893. 
16 


242       THE  FUXCTIOXAL   PATHOGENESIS  OF  DEFORMITY 

length  of  the  legs  is  not  at  all  uncommon.  Inequality  of  the  two 
halves  of  the  body  may  be  congenital,  and  it  may  be  evident  at 
birth,  but  ustially  it  does  not  attract  attention  until  adolescence. 
In  many  instances  this  inequality  is  a  slight  atrophy,  the  result  of  a 
cerebral  hemiplegia  of  early  childhood.  In  other  instances  the  in- 
equality may  be  due  to  congenital  hypertrophy  that  may  affect  the 
entire  limb.  In  such  cases  the  enlargement  may  be  due  to  an  abnor- 
mal amomit  of  normal  tissue,  but  in  most  instances  the  hypertrophy, 
which  becomes  more  marked  with  the  growth  of  the  child,  is  caused 
by  an  abnormal  blood  supply,  a  form  of  congenital  nevus  (Fig.  205). 


Table  of  Weight,  Height,  axd  Circumferenxe  of  the  Chest  ix 
Chii.dhood.     (Boas.) 


Pounds.       Kilos. 


Height. 


Chest 


Inches       Cm.       In?hes     Cm. 


Birth 


6  months 


1  year 
18  months 


2  years 


10 


11 


12 


1.3 


1-4 


15 


Male 
Female 
Male 
Female 
Male 
Female 
Male 
Female 
Male 
Female 
Male 
Female 
Male 
Female 
/  Male 
I  Female 
(  Male 

Female 
;  Male 

Female 
;  Male 

Female 
/  Male 
I  Female 
^  Male 
Female 
Male 
Female 
Male 
Femiale 
Male 
Female 
Male 
Female 
Male 
Female 


7.16 
16.0 
15.5 
20.5 
19.8 
22.8 
22.0 
26.5 
25 . 5 
.31.2 
.30.0 
35.0 
34.0 
41.2 


39.8 
45.1 
43.8 
49.5 
48.0 
54.5 
52.9 
60.0 


66.6 

64.1 

72.4 

70.3 

79.8 

81.4 

88.3 

91.2 

99.3 

100.3 

110.08 

108.04 


3.43 
3.26 
7.26 
7.03 
9.29 
8.84 
10 .  .35 
9.98 
12.02 
11.56 
14.14 
13 .  60 
15.87 
15.41 
18.71 
18.06 
20.48 
19.87 
22.44 
21.78 
24.70 
24.01 
26.58 
26.10 
30.22 
29.07 
32 .  83 
31.87 
36.21 
36.90 
40.04 
41.36 
45 .  03 
45.50 
50.26 
49.17 


20.6 
20.5 
25.4 
25.0 
29.0 
28.7 
30.0 
29.7 
32.5 
32.5 
35 . 0 
35 . 0 
.38.0 
38.0 
41.7 
41.4 
44.1 
43.6 
46.2 
45.9 


52.2 

64.8 

64.6 

73.8 

73.2 

76.3 

75 .6 

82.8 

82.8 

89.1 

89.1 

96.7 

96.7 

106.8 

105.3 

112.0 

110.9 

117.4 

116.7 


48.2 

122.3 

48.0 

122.1 

50.1 

127.2 

49.6 

126.0 

52.2 

1.32.6 

51.8 

131.5 

.54.0 

137.2 

53.8 

136.6 

55.8 

141.7 

57.1 

145.2 

5S.2 

147.7 

58.7 

149.2 

61.0 

155.1 

60.3 

153.2 

63.0 

159.0 

61.4 

155.9 

13.4 
13.0 
16.5 
16.1 
18.0 
17.4 
18.5 
18.0 
19.0 
18.5 
20.1 
19.8 
20.7 
20.5 
21.5 
21.0 
23.2 
22.8 
23.7 
23.3 
24.4 
23.8 
25.1 
24.5 
25.8 
24.7 
26.4 
25.8 
27.0 
26.8 
27.7 
28.0 
28.8 
29.2 
.30.0 
30.3 


34.2 

33.2 

42.0 

41.0 

45.9 

44.4 

47.1 

45.9 

48.4 

47.0 

51.1 

50.5 

52.8 

52.2 

54.8 

53.5 

59.1 

58.3 

60.6 

59.5. 

62.2 

60.8 

63.9 

62.5 

65.6 

63.0 

67.2 

65.8 

68.8 

68.3 

70.6 

71.3 

73.3 

74.1 

76.6 

79.8 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY. 

Wolff's  Law. — "  Every  change  in  the  form  and  function  of  the 
bones  or  of  their  function  alone  is  followed  by  certain  definite  changes 


WOLFF'S  LAW 


243 


in  their  internal  architecture,  and  equally  definite  secondary  alter- 
nations of  their  external  conformation,  in  accordance  with  mathe- 
matical laws." 

Mention  has  been  made,  and  will  be  made  again  from  time  to 
time,  of  the  adaptation  of  the  body  to  abnormal  conditions,  and  of 
the  transformation  of  deformed  parts  to  the  normal  when  the  im- 
proper relations  of  weight  and  strain  have  been  removed.  Wolff 
first  called  attention  to  the  fact  that  the  shape  of  a  bone  is  the  effect 
of  function.  *  It  is  the  eftect  of  function  in  that  if  the  work  required 


Fig.  206. 


-Dislocated  femur,  showing  the  atrophy  and  rearrangement  of  the  interna 
structure  as  compared  with  the  normal  (Fig.  207).     (Freiberg.) 


of  it  had  been  different  its  shape  would  have  been  different.  This 
function  has  shaped  not  only  the  external  contour  but  the  internal 
structure  as  well.  If  a  bone  is  broken,  for  example  the  neck  of  the 
femur,  and  deformity  results,  the  internal  architecture  is  no  longer 
suitable  for  the  new  conditions  of  weight  and  strain,  and  immediately 
a  rearrangement  begins,  which  finally  transforms  the  internal  struc- 
ture, not  only  in  the  neighborhood  of  the  injury,  but  in  the  extremity 
of  the  bone  also,  to  adapt  the  deformed  part  as  well  as  may  be  to  the 
work  that  is  now  demanded  of  it. 

The  normal  bone  is  braced  most  thoroughly,  and  is  most  resistant 


244     THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY 

at  the  points  where  most  work  is  required  of  it.  If  the  weight  and 
strain  are  for  any  reason  transferred  to  another  part,  its  structure 
is  strengthened  there,  and  correspondingly  weakened  at  the  point 
from  which  the  strain  has  been  removed.  With  this  change  in  the 
internal  structure  a  change  in  the  external  contour  keeps  pace.  For 
according  to  this  theory,  "the  external  contour  represents  mathe- 
matically simply  the  last  curve  uniting  the  ends  of  the  various 
trajectories  which  make  up  the  internal  structure." 

For  the  further  exposition  of  this  theory  I  quote  from  Freiberg's^ 
review  an  abstract  of  Wolff's^  final  article. 


Fig.   207. — Normal  femur  from  same  subject.      (Freiberg.) 

"  In  showing  that  improper  static  demands  made  upon  an  extrem- 
ity resulted  in  the  formation  of  new  masses  of  bone  upon  the  svirface 
of  the  bone  of  this  extremity,  or  that  they  produce  the  disappearance 
(atrophy)  of  bone  masses  according  to  the  nature  and  degree  of 
these  disturbances  in  static  requirements,  it  has  at  once  been  shown 
in  what  manner  deformities  have  their  origin.  For  these  trans- 
formations on  the  surface  of  bone  are  nothing  other  than  'deformi- 
ties' in  the  wider  or  narrower  sense  of  the  term. 

1  Ann.  Surg.,  July,  1897;  and  Am.  Jour.  Med.  Sc,  December.  1902. 

2  Die  Lehre  von  der  functionellen  Pathogenese  der  Deformitaten,  Arch.  f.  klin. 
Chir.,  Band  liii.  Heft  4. 


WOLFF'S  LAW 


245 


"Taking  genu  valgum  or  habitual  scoliosis  as  an  example,  the 
development  of  a  deformity  in  the  narrow  sense  is  thus  explained. 
In  the  beginning  of  either  of  these  conditions  the  shape  of  the  bones 
is  perfectly  normal.  As  the  result  of  excessive  fatigue  in  their  too 
weak  muscles  the  patients  are  frequently  assuming  a  faulty  position 
of  limb  or  body;  they  seek  to  control  excessive  excursions  of  their 
joints  by  the  interference  of  the  articular  structures  themselves 
instead,  of  b^  muscular  activity.  The  result  is  a  continual  altera- 
tion in  the  static  requirements  made  upon  the  bones  and  the  internal 
architecture;  internal  and  external  configuration  of  the  bones 
accommodate  themselves  to  the  new  conditions.  Since,  according 
to  this  reasoning,  deformities  are  nothing  less  than  the  result  of 
these  transformations  which  the  external  form  of  bones  or  joints 
undergo  in  accommodating  itself   to  faulty  demands  made  upon 


Fig.  208. — Section  of  femoral  head  of  a  paralytic  idiot,  aged  thirty-five  years,  showing 
the  extreme  atrophy  caused  by  disuse.      (R.  T.  Taylor.) 


them,  it  must  be  self-evident  that  these  deformities  are  to  be  con- 
sidered pathological  only  in  the  sense  that  hypertrophy  of  the  cardiac 
muscle  in  valvular  insufficiency  is  pathological.  That  which  is 
really  pathological  is  only  the  altered  static  requirements,  the  abnor- 
mal mechanical  function.  Far  from  being  pathological  the  deform- 
ity is  the  only  suitable  or  even  possible  form  by  means  of  which  bone 
or  joint  can  withstand  the  altered  forces  bearing  upon  it;  it  is 
Nature's  way  of  securing  the  greatest  possible  service  and  strength, 
under  new  conditions,  with  the  use  of  the  least  possible  amount  of 
material. 

"The  pathogenesis  of  deformities  is  therefore  functional.  Genu 
valgum,  for  instance,  represents  only  the  functional  accommodation 
of  femur,  tibia,  and  knee-joint  to  the  improper  static  demands  made 
by  the  outward  deviation  of  the  leg.  Just  so  are  the  shapes  of  the 
bones  in  club-foot  the  expressions  of  similar  functional  accommoda- 


246     THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY 

tion  to  an  inward  rotation  of  the  foot,  or  even,  sometimes,  an  inward 
turning  of  the  whole  lower  extremity.  The  faulty  position  of  an 
extremity  under  these  circumstances  is  to  be  regarded  rather  as  a 
cause  of  the  deformity  than  as  an  effect.  This  faulty  position  must 
always  occupy  a  place  intermediate  between  the  remote  causes  of 
deformity  (hereditary  predisposition,  habit,  muscular  weakness, 
external  conditions  causing  pressure  or  narrowing  space  of  growth), 
and  the  anatomical  results  which  these  various  remote  causes  bring 
about. 

''When  the  altered  demands  upon  an  extremity  do  not  occur 
spontaneously,  as  in  the  above  instances,  but,  on  the  other  hand, 
result  from  a  primary  disturbance  in  the  shape  of  the  bones,  due 
to  trauma  or  bone  disease  with  consequent  softening  or  destruction 
of  tissue,  there  is  added  to  this  a  secondary  change  in  the  external 
configuration  of  the  bones,  and  there  is  thus  caused  a  'deformity  in 
the  broad  sense  of  the  word.'  The  difference  between  the  two 
varieties  of  deformity  therefore  lies  only  in  the  addition  of  a  second 
etiological  factor  (the  trauma,  etc.)  to  the  deformity  in  the  broad 
sense.  Both  varieties  have  it  in  common  that  the  shape  of  the  bones 
and  joints  of  the  deformed  part  represents  nothing  else  than  the 
expression  of  a  functional  accommodation  to  the  faulty  static  de- 
mands made  upon  it. 

"As  a  second  example  by  means  of  which  to  explain  the  correct- 
ness of  the  doctrine  of  functional  pathogenesis  the  author  has 
selected  scoliosis.  In  the  first  chapter  the  author  showed  in  detail 
that  the  altered  conditions  in  the  length  and  height  of  the  trans- 
verse processes  of  scoliotic  vertebrae  as  well  as  corresponding  condi- 
tions in  the  ribs  of  the  scoliotic  thorax  are  so  evident  as  not  possibly 
to  escape  notice,  and  that  they  can  be  explained  in  no  other  way  than 
as  functional  accommodation  to  the  circumstances  of  space,  changed 
and  brought  about  by  the  continual,  faulty,  and  cramped  position 
of  the  thorax ;  this  is  as  true  of  the  convex  as  of  the  concave  side  of 
the  vertebral  column,  to  which  the  transverse  processes  and  ribs  in 
question  belong.  It  must  be  manifest  that  changed  relations  of  one 
part  of  the  skeleton  to  any  other  part  of  the  skeleton  (as  far  as  space 
conditions  are  concerned)  necessarily  bring  about  changes  in  the 
mechanical  demands  made  upon  this  part,  and  therefore  changes 
in  the  directions  and  values  of  the  pressure,  tension,  and  shearing 
strains  of  each  and  every  point  in  this  part  of  the  skeleton.  The 
conclusion  thus  drawn,  that  accommodation  to  space  means  the 
same  as  accommodation  to  function,  is  of  greatest  importance  to  the 
general  doctrine  of  functional  accommodation. 

"The  origin  of  the  wedge-shape  of  the  scoliotic  vertebra  now 
comes  under  discussion.  It  is  assumed  by  the  majority  of  writers 
that  an  abnormal  softness  of  the  bones  is  present  in  scoliosis  by 
means  of  which  a  faulty  position  can  model  the  bodies  of  the  verte- 
brse  as  it  does  in  the  case  of  rhachitic  disease  of  the  bone,  or  as  is  really 


Atrophy  of  bone  24f 

the  case  with  the  intervertebral  disks  in  cases  of  'habitual  scoliosis.' 
While  unsupported  by  any  pathologico-anatomical  investigations, 
it  is  allowed  possible,  or  even  probable,  that  such  softness  of  the 
bones  plays  a  role  in  many  cases  of  scoliosis.  It  is  certain,  however, 
that  this  is  by  no  means  always  the  case;  as  evidenced  by  the  de- 
velopment of  scoliosis  after  empyema  in  adults,  and  the  great 
exaggeration  in  adult  life  of  very  slight  scolioses  originating  during 
youth.  It  is  concluded,  on  the  contrary,  that  the  vertebra  may 
acquire  its*scoliotic  wedge-shape  entirely  independent  of  the  pres- 
sure of  the  superincumbent  weight.  Furthermore,  in  the  absence 
of  any  abnormal  softness  of  the  bones  the  body  of  a  vertebra  may 
lose  height  on  the  concave  side  and  gain  the  same  on  the  convex  side 
through  the  'trophic  stimulus  of  function'  purely;  being  simply  an 
accommodation  to  the  diminished  space  on  the  concave  side  and 
increased  room  at  the  convexity  and  the  change  of  mechanical  con- 
ditions consequent  thereupon. 

"This  simple  and  natural  conception  of  the  circumstances  con- 
cerning the  sciolotic  wedge  must  obtain  credence,  especially  since 
the  old  view,  corresponding  to  the  'pressure  theory,'  has  been  long 
ago  disproved  by  Hoffa  and  Nicoladoni — namely,  that  the  concave 
side  of  the  wedge  is  the  seat  of  atrophy,  and  that  this  atrophy 
accounts  for  the  loss  in  height  of  the  vertebral  body  on  this  side." 

The  importance  of  Wolff's  theory,  which  shows  how  deformity 
may  be  acquired  and  how  it  may  be  avoided,  is  very  evident.  It  is 
of  equal  importance  in  indicating  the  principles  of  treatment.  For 
example,  from  the  anatomical  description  of  a  club-foot  the  distor- 
tion might  appear  to  be  irremediable,  but  on  this  theory  one  feels 
assured  that  if  the  foot  can  be  fixed  for  a  sufficient  time  in  the  over- 
corrected  position,  the  influence  of  the  new  static  conditions  will 
induce  a  gradual  transformation,  not  only  in  soft  parts,  but  in  the 
bones  as  well,  that  will  finally  effect  a  complete  cure.  So,  also,  the 
correction  of  a  distorted  bone  by  operative  means  is  at  best  imper- 
fect; if,  however,  the  static  conditions  have  been  changed,  nature 
will  in  time  reconstruct  the  entire  bone  so  perfectly  that  in  a  few 
years  practically  no  trace  of  the  former  distortion,  either  in  contour 
or  internal  structure,  will  be  evident.  Scoliosis  might  be  cured  as 
perfectly  as  the  club-foot  or  the  bow-leg,  were  it  possible  to  restore 
as  easily  the  normal  conditions  of  weight  and  strain. 

ATROPHY  OF  BONE. 

The  writings  of  Wolff  have  emphasized  the  fact  that  bone  is  a 
living  tissue  very  readily  affected  by  changing  conditions,  and  that 
atrophy  or  hypertrophy  may  be  local  or  general,  according  to  the 
change  in  functional  use  of  the  affected  part. 

Since  the  Roentgen  rays  have  come  into  general  use  particular 
attention  has  been  called  to  the  atrophy  of  the  internal  structure  of 


248  HYPERTROPHY  OF  BONE 

bone  that  follows  lessened  use  or  disuse,  or  from  what  is  called  trophic 
disturbance  of  nutrition  from  any  cause.  For  example,  after  frac- 
ture or  joint  disease,  or  nervous  affections,  or  even  slight  injuries 
of  the  nature  of  sprains,  atrophy  of  the  lamellse  of  the  spongy  por- 
tion and  of  the  compact  substance  of  the  bone  is  soon  apparent. 

This  atrophy  is  not  only  rapid,  but  it  may  be  widespread,  as 
proved  by  the  investigations  of  Sudeck,^  who  could  distinguish 
atrophy  of  the  bones  of  the  foot  within  six  weeks  after  fracture  of 
those  of  the  leg.  Atrophy  of  bone  is  especially  rapid  as  a  result  of 
acute  affections  of  the  joints,  corresponding  in  this  to  the  atrophy 
of  the  muscles  under  similar  conditions.  In  the  .r-ray  negative 
such  atrophy  is  indicated  by  a  loss  of  clearness  of  outline  which  is 
replaced  by  a  peculiar  blur,  resembling  closely  the  infiltration  due 
to  disease. 

These  nutritive  changes  explain  the  delay  in  recovery  after  appar- 
ently slight  injury  or  disease  of  a  joint  or  other  tissue.  The  treat- 
ment therefore  should  be  stimulative,  and  functional  use  of  the 
weak  part  should  be  encouraged  as  soon  as  possible.^ 

After  long-continued  disuse  the  bones  may  be  extremely  fragile 
and  in  those  who  have  suffered  from  wasting  disease  there  may  be  a 
fibrous  transformation  of  the  bone  tissue.  This  must  be  borne  in 
mind  when  one  attempts  to  correct  deformity  caused  by  paralysis, 
by  chronic  joint  disease,  and  the  like. 

HYPERTROPHY  OF  BONE. 

This  is  usually  due  to  disease.  It  may  be  general,  as  in  osteitis 
deformans.  It  may  affect  corresponding  bones,  as  in  syphilitic 
enlargement  and  elongation  of  the  tibise,  or  it  may  be  limited  to  a 
single  bone.  Of  this  a  familiar  example  is  chronic  osteomyelitis, 
which  may  induce  thickening,  and  elongation  of  the  affected  bone 
sometimes  to  the  extent  of  two  or  more  inches. 

1  Fortsc.  auf  dem  Gebiets.  der  Rontgenstrahlen,  Band  iii,  Heft  G. 

2  Mally  et  Richon:  Rev.  de  Chir.,  xxiv  and  xxv. 


CHAPTER  V. 
TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

Etiology. — Three  factors  are  recognized  in  the  etiology  of  tuber- 
culous disease:  the  infectious  element  (the  tubercle  bacillus),  the 
predisposition  of  the  patient,  and  the  local  condition  that  favors  the. 
reception  and  the  growth  of  the  bacilli. 

Predisposition. — The  predisposition,  both  general  and  local,  is 
spoken  of  as  lessened  vital  resistance.  A  general  predisposition 
to  disease  may  be  inherited  or  it  may  be  acquired.  Thus,  a  history 
of  tuberculosis  in  the  immediate  family  of  the  patient  is  supposed 
to  imply  a  lessened  resistance  to  this  form  of  disease.  In  a  certain 
proportion,  perhaps  25  per  cent.,  of  the  cases  this  inherited  predis- 
position is  very  direct  and  positive,  but  in  the  larger  number  the 
family  history  is  as  indefinite  as  in  a  similar  class  of  patients  under 
treatment  for  any  other  disease.  The  acquired  predisposition  is  of 
more  direct  importance,  since  it  would  include  the  lessened  vitality 
due  to  improper  food  and  improper  hygienic  surroundings  of  every 
variety,  together  with  the  greater  liability  to  depressing  diseases 
and  the  more  constant  exposure  to  tuberculous  infection  that  such 
conditions  imply.  Thus,  tuberculous  disease  of  the  bones,  as  well 
as  of  other  parts,  is  more  common  among  the  poor  of  cities  than 
among  the  more  favored  classes. 

Mode  of  Infection. — The  tubercle  bacilli  may  be  introduced  to  the 
body  by  inhalation  and  find  their  way  to  the  bronchial  glands,  or 
by  the  mouth  and  set  up  disease  in  the  mesenteric  glands,  or  infec- 
tion through  the  nasal  passages  or  neighboring  parts  may  cause 
disease  of  the  cervical  lymphatics. 

Latent  Tuberculosis. — It  may  be  assumed  that  disease  of  the  bron- 
chial and  mesenteric  glands  is  not  uncommon  in  individuals  of 
apparently  perfect  health,  since  it  is  often  discovered  at  autopsies 
in  those  who  have  died  from  other  causes.  For  example  in  2713 
autopsies  on  children  who  died  of  acute  infectious  diseases  reported 
by  Ganghofner  tuberculous  disease  was  found  in  562  or  about  20 
per  cent.  Rothe  and  Gaffke^  inoculated  guinea-pigs  with  the 
material  from  the  bronchial  and  mesenteric  glands  obtained  from 
400  cadavers  of  children,  with  78  positive  results  (19.5  per  cent.). 
This  form  of  glandular  disease  is  called  latent  tuberculosis.  In 
many  instances  the  disease  may  remain  latent  and  finally  disappear, 
or  it  may  persist,  and  from  time  to  time  free  bacilli  or  bits  of  infected 

1  Deutsch.  med.  Wchnschr.,  July  23,  1911. 


250        TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 

tissue  may  escape  into  the  blood  and  are  deposited  in  other  parts, 
where,  under  favoring  conditions,  local  disease  may  be  set  up.  De- 
pression of  the  vitality  from  any  cause  should  favor  the  progress  of 
the  glandular  disease,  and  dissemination  of  the  infectious  elements. 
It  should  also  lessen  the  resistance  of  the  tissues  exposed  to  infec- 
tion. This  accounts  for  the  well-known  influence  of  certain  dis- 
eases, such  as  measles  and  whooping-cough,  not  only  in  predisposing 
to  local  tuberulous  disease,  but  in  favoring  its  progress  when  it  is 
already  estabhshed.  It  is  possible  also  that  the  bacilli  that  have 
found  their  way  into  the  blood  current  more  directly,  as  for  example, 
through  wound  infection,  may  set  up  primary  disease  of  a  bone 
or  joint.  In  fact  it  is  stated  by  Konig^  that  in  14  of  67  autopsies 
on  subjects  who  had  suffered  from  tuberculous  disease  of  the  bones 
and  joints  no  other  foci  were  found  in  the  body.  In  other  instances 
the  source  of  infection  may  be  preexistent  disease  of  the  lungs  or 
of  other  internal  organs. 

In  769  autopsies  on  children  under  twelve  years  of  age  at  the 
Hospital  for  Children,  Great  Ormond  Street,  London,  reported  by 
G.  F.  Still,2  269  presented  tuberculous  lesions.  Of  these  117  were 
less  than  two  years  of  age. 

The  apparent  channels  of  infection,  as  evidenced  by  the  appear- 
ance of  the  glandular  lesions,  were  as  follows: 

Rnspiratory : 

Lungs 105 

Probably  lungs 33 

Ear 9 

Probably  ear 6 

153   =57.0  per  cent. 
Alimentary : 

Intestines 53 

Probably  intestines 10 

63   =23.4  per  cent. 
Other  cases: 

Bones  or  joints 5 

Fauces       2 

Uncertain 46 

53 

Northrup  and  Bovaird^  have  made  similar  observations  at  the 
New  York  Foundling  Hospital: 

Infection  by  respiratory  tract 148 

Infection  by  mesenteric  lymph  nodes 3 

Indeterminate 48 

199 

In  16  instances  the  process  was  confined  to  the  bronchial  glands, 
and  in  no  instance  were  these  glands  found  to  be  free  from  disease. 

1  Deutsch.  Chir.,  1900,  L.  28a,  S.  157. 

2  British  Med.  Jour.,  August  19,  1899. 

3  Northrup:  New  York  Med.  Jour.,  February  21,  1891;  Bovaird:  Ibid.,  July  1 
1899. 


ETIOLOGY  251 

Bovaird^  has  collected  the  reported  autopsies  on  tuberculous 
children  with  reference  to  primary  intestinal  infection,  and  has 
called  attention  to  the  fact  that  the  English  observations  are  not 
in  accord  with  others : 

Primary  intestinal 
Autopsies.  diseases. 

German 236  9=4  per  cent. 

French 128  0 

English 748  136  =  18 

American 369  5=1 

1481  150 

Haushalter,^  in  78  autopsies  upon  children  dying  from  acute 
miliary  tuberculosis,  found  in  all  but  4  disease  of  the  tracheo- 
bronchial glands.  In  44  this  disease  was  the  most  ancient  focus  in 
the  body. 

Peterka^  in  216  cases  of  surgical  tuberculosis  found  evidence  of 
infection  during  the  first  three  years  of  life  in  199.  He  concludes 
that  complete  cure  of  infection  in  early  childhood  is  not  attained 
in  more  than  half  the  cases,  and  that  it  is  an  important  factor  in 
tuberculous  disease  of  later  life. 

Local  Predisposition. — The  local  conditions  that  favor  the  growth 
of  the  tubercle  bacilli  may  be  induced  by  injury.  Slight  injury 
sufficient  to  cause,  for  example,  a  hemorrhage  into  the  substance  of 
the  cancellous  tissue  induces  a  local  congestion  during  the  process 
of  repair  that  provides  the  proper  soil  for  the  growth  of  the  bacilli 
when  they  are  deposited  in  its  neighborhood.  This  has  been  proved 
experimentally  by  Krause,  and  Ribera,^  and  it  is  supported  by  clini- 
cal evidence.  The  great  preponderance  of  disease  in  the  lower  over 
that  of  the  upper  extremities  in  childhood  may  be  cited  as  evidence 
of  the  influence  of  injury  in  the  causation  of  disease. 

In  577  of  3539  cases  of  tuberculosis  of  the  bones  and  joints 
reported  by  Hildebrand,^  Konig,  Mikulicz,  Bruns  and  Ribera  injury 
seemed  to  be  a  direct  predisposing  cause  of  the  local  disease  (16.3 
per  cent.).  A  much  higher  percentage  than  this  has  been  assigned 
by  certain  writers,  but  the  exact  relation  of  traumatism  to  disease 
can  only  be  conjectured.  For  example,  Voss^  in  577  cases  treated 
at  Rostock  found  injury  stated  as  the  exciting  cause  in  more  than  20 
per  cent.  Yet  on  further  investigation  in  but  7  per  cent,  could  its 
influence  be  clearly  established.'^ 

The  primary  disease  is  almost  always  in  the  newly  formed  bone 
about  the  conjugal  cartilage  more  often  apparently  on  the  dia- 
physeal side.     This  tissue  is  vulnerable;  it  is  more  exposed  to  direct 

1  Arch.  Pediat.,  December,  1901. 

2  Arch,  de  Med.  des  Enfants,   March,   1902. 

3  Beit.  z.  klin.  Chir.,  1912,  viii.  "  Presse.  Med.,  May  13,  1910. 
6  Deutsch.  Chir.,  1902,  L.  13,  S.  168.                  «  Ztschr.  f.  Chir.,  1904,  No.  16. 

^  The  literature  of  the  subject  may  be  found  in  the  Arch.  f.  orthop.  Mechanico- 
therapie  u.  Unfall  Chir.,  1906,  Band  iv.  Heft  4,  Deutschlander. 


0.V7 


TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 


injury;  it  is  subjected,  also,  to  the  strain  of  motion  at  the  neighbor- 
ing joint,  and  as  the  circulation  is  here  more  active  the  bacilli  are 
more  often  deposited  in  this  situation. 

Ilibera^  found  evidence  of  injury  in  64  of  141  cases  of  disease  of 
the  larger  joints.  He  states  that,  experimentally,  tubercle  bacilli 
have  an  especial  predilection  for  bone  marrow  and  that  synovial 
membrane  is  very  resistant  to  infection  unless  it  is  injured. 

The  vulnerability  of  growing  bone  accounts  also  for  the  relative 
frequency  of  bone  disease  in  childhood,  as  compared  with  adult 
life,  Injm-y  not  only  causes  a  local  predisposition  to  disease,  but 
it  favors  its  progress  when  it  is  once  established. 

Distribution  of  the  Disease. — In  13,308  cases  of  tuberculous  disease 
of  the  bones  and  joints  treated  at  the  Hospital  for  Ruptured  and 
Crippled  the  distribution  was,  in  order  of  frequency,  as  follows: 

Vertebrge 5,682        =42.5  per  cent. 

Hip-joint 4,048        =30.5 

Other  joints 3,598       =27.0 

13,308 

In  a  total  of  3561  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled  and  at  the  Vanderbilt  Clinic  during  a  period  of  five  years 
the  distribution  was  as  follows: 

Vertebrge 1432  =40.2  per  cent. 

Hip-joint 1123  =31.5 

Knee-joint 699  =19.6 

Ankle-joint 196  =5.5           " 

Elbow-joint 62l 

Shoulder-joint 42!-  =     3.1 

Wrist-joint 7j 

3561 

Trunk 1432  =40.2 

Lower  extremities 2018  =56.6  " 

Upper  extremities Ill  =3.1  " 

The  correspondence  between  these  two  tables  of  statistics  is  strik- 
ing, and  the  nmnber  of  cases  is  so  large  that  the  proportions  may  be 
accepted  as  approximately  correct  as  applied  'to  the  distribution  of 
the  disease  in  childhood. 

At  the  Boston  Children's  Hospital  in  a  period  of  twenty-five  years, 
1869-1893,  3820  cases  were  treated.-  The  distribution  was  as 
follows : 

Vertebrae 1964  =  51.4  per  cent. 

Hip 1402  =36.7 

Ankle 300  =7.8 

Knee 104  =2.7 

Wrist 20  1 

Shoulder 15^=1.3           " 

Elbow 15  J 

3820 

Trunk 1964  =  51.4  " 

Lower  extremities 1806   =47.2  " 

Upper  extremities 50   =     1 . 3  " 

iPresse,  Med.,  May  13,  1910.         -  Report  of  the  Boston  Children's  Hospital. 


ETIOLOGY 


253 


Side  Affected. — Disease  of  the  joints  is  slightly  more  common 
on  the  right  than  on  the  left  side  of  the  body.  At  the  Hospital 
for  Ruptured  and  Crippled  the  proportions  in  the  cases  treated 
during  a  recent  period  of  ten  years  are  as  follows: 

Hip,  right 53  per  cent. 

Knee,  right 55 

Ankle,  right 50 

Shoulder,  right 64 

Elbow,  right 60  " 

It  has  been  stated  that  one  of  the  explanations  of  the  great  pre- 
ponderance of  the  disease  of  the  lower  over  the  upper  extremity 
is  the  greater  hability  to  injury.  The  same  explanation  has  been 
advanced  to  account  for  the  greater  frequency  of  disease  on  the 
right  side,  w^hich  is  more  marked  in  the  upper  than  in  the  lower 
extremity,  because  the  right  arm  is  more  liable  to  overwork  as 
well  as  to  injury. 

Sex. — Tuberculous  disease  of  the  joints  is  somewhat  more  common 
among  males  than  females. 

Of  .3822  cases  of  Pott's  disease  treated  at  the  Hospital  for  Rup- 
tured and  Crippled,  2037,  or  53  per  cent.,  were  in  males. 

Of  3307  cases  of  disease  of  the  hip-joint  treated  at  the  same 
institution,  1731,  or  52.3  per  cent.,  were  in  males. 

Of  1218  cases  of  disease  of  the  knee-joint,  combined  statistics  of 
Konig  and  Gibney,  703,  or  57.6  per  cent.,  were  in  males. 

Age. — In  5461  cases  of  tuberculous  disease  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled,  about  seven-eighths  of  the  patients 
were  less  than  fourteen  years  of  age. 


Less^than  14  years  of  age 


t^ 


Between  14  and  21  years  of  age 


More  than  21  years  of  age 


vertebrae,  87.7  per  cent, 

hip,  88.2 

other  .ioints,  71.7  " 

vertebrae,  7.7  " 

hip,  9.2 

other  joints,  10.7  " 

vertebrae,  4.5  " 

hip,  2.5 

[  other  joints,  17. 5^  " 


Of  1259  eases  of  Pott's  disease  treated  recently  at  the  same 
institution,  1075,  or  85  per  cent.,  of  the  patients  were  in  the  first 
decade;  50  per  cent,  were  three  to  five  years  of  age,  inclusive,  at 
the  inception  of  the  disease. 

In  1000  cases  of  disease  of  the  hip-joint  the  ages  of  the  patients 
correspond  closely  to  these;  87.2  per  cent,  were  in  the  first  decade 
and  45.2  per  cent,  were  from  three  to  five  years  of  age,  inclusive. 

In  1000  cases  of  disease  of  the  knee-joint,  75  per  cent,  were  in 


1  Knight:  Orthopedia. 


254        TUBERCULOUS  DISEASE  OF  BOXES  AXD  JOINTS 

the  first  decade  and  40  per  cent,  were  from  three  to  five  years, 
inchisive. 

In  339  cases  of  the  ankle-joint,  70  per  cent,  were  in  the  first 
decade  and  35  per  cent,  within  the  first  three  years  of  hfe. 

The  distribution  of  the  disease  and  its  relative  frequency  at  the 
difterent  ages  is  shown  by  Alfer's  table  of  statistics  from  Trendelen- 
burg's clinic  at  Bonn.^ 


? 

o 

•o 

o 

o 

CO 

o 

o 
>o 

o 
o 

CO 

o 

•7 

•q 

lO 

o 

to 

o 
n 

3 

CO 
6 

o 
3 

u4 

1 

o 
m 

4 

0 

o 

o 

0 

o 
0 

Vertebrae 

89 

59 

32 

23 

9 

10 

239 

Hip  .      . 

58 

59 

43 

46 

9 

11 

6 

0 

4 

1 

1 

3 

0 

0 

241 

Knee 

47 

52 

47 

37 

20 

11 

23 

11 

11 

3 

o 

s 

6 

3 

281 

-Inkle     . 

o 

9 

10 

5 

2 

1 

1 

3 

0 

0 

3 

0 

o 

0 

43 

Shoulder 

0 

2 

2 

6 

3 

5 

3 

1 

1 

9 

•-) 

1 

0 

0 

28 

Elbow     . 

/ 

14 

14 

21 

12 

9 

6 

5 

9 

8 

5 

2 

2 

0 

114 

Wrist 

1 

0 

0 

1 

5 

0 

0 

3 
29 

1 
3. 

3 
18 

2 
19 

1 
15 

3 

13 

0 
3 

20 

Total 

207 

195 

148 

139 

60 

47 

42 

966 

This  table  illustrates  the  well-known  fact  that  disease  of  the 
upper  extremity,  relatively  infrequent  at  all  ages,  is  proportionately 
far  more  common  in  adult  life.  Of  the  joints  of  the  lower  extremity, 
the  knee  and  the  ankle  are  proportionately  more  often  diseased  in 
later  life  than  is  the  hip. 

The  common  type  of  infection  in  this  country  is  with  the  human 
bacillus,  but  in  bottle-fed  children  the  bovine  form  is  not  uncom- 
mon in  certain  localities.  Fraser  investigated  70  cases  of  tubercu- 
losis of  the  bones  and  joints  of  children  under  twelve  years  of  age. 
In  41  bovine  bacillus  was  found,  in  26  human,  and  in  3  both 
varieties.- 

Pathology. — When  the  baciUi  are  deposited  in  a  part,  the  irrita- 
tion of  theu-  toxins  causes  a  proliferation  of  the  fixed  cells  which 
lie  in  direct  contact  with  the  germs,  and  about  these  a  ring  of 
leukoc\-t.es  forms.  The  bacilli,  the  epitheloid  cells  including  often 
one  or  more  giant  cells,  together  with  the  smrounding  leukoc.vtes, 
constitute  the  visible  tubercle  of  bone,  a  minute  grayish  speck  in 
the  cancellous  structme.  The  central  cells  about  the  bacilli, 
increasing  in  nimiber,  deprived  of  nourishment  by  the  obliteration 
of  the  blood  spaces  and  poisoned  by  the  toxins,  die  and  are  disin- 
tegrated to  granular  material,  "caseate,"  and  the  tubercle  changes 
to  a  yellow  color;  but  the  bacilH,  multiplying  and  escaping,  form 
new  tubercles  about  the  original  focus,  which  coalesce  as  the  area 
of  the  disease  enlarges.  ^Meanwhile  the  surrounding  tissue  becomes 
congested  as  the  result  of  the  irritation,  and  the  fixed  cells  become 
organized,   or  partly  organized,  into  a  feeble,  ill-nourished  form 

1  Beitr.  z.  klin.  Chir.,  Band  ^-iii.  Heft  2. 
-  Jour.  Am.   Med.  Assn.,  January  2,   1915. 


PATHOLOGY  255 

of  granulation  tissue,  representing  an  etl'ort  to  shut  out  and  to 
expel  the  foreign  substances  formed  by  the  disease.  Or,  if  this 
local  resistance  is  effective,  the  cells  become  organized  into 
firm  granulations  which  surround  and  destroy  the  germs,  and 
then  are  further  transformed  into  scar  tissue.  But  in  most  instances 
either  because  the  irritation  is  insufficient  or  because  of  the  defi- 
cient vitality  of  the  part,  the  granulations  are  feeble  and  unstable, 
and  they  in  turn  becoming  infected  by  the  multiplying  bacilli 
serve  only  to  extend  the  area  of  the  disease.  This  granulation 
tissue,  before  and  after  the  stage  of  infection,  absorbs  and  destroys 
the  bone.  If  the  progress  of  the  disease  is  slow,  the  cancellous 
structure  is  completely  absorbed  or  is  represented  only  by  "bone 
sand,"  but  if  the  disease  infiltrates  the  bone  more  rapidly  it  may 
destroy  its  vitality  while  its  structure  is  still  retained,  and  a  seques- 
trum is  formed.  Such  sequestra,  consisting  of  rounded,  yellow, 
crumbling  masses  of  cancellous  structure,  of  the  size  of  a  pea  or 
larger,  are  especially  common  in  epiphyseal  disease  of  childhood. 
In  rare  instances  wedge-shaped  sequestra  are  found  with  the  base 
at  the  periphery  of  the  epiphysis.  These  are  apparently  caused 
by  the  lodging  of  an  infected  embolus  in  a  terminal  vessel,  thus 
cutting  off  the  blood  supply. 

By  the  formation  of  new  tubercles  at  the  periphery  and  by  the 
caseation  of  material  in  the  centre  of  the  diseased  area  a  cavity 
in  the  bone  is  formed,  containing  granulation  tissue,  often  sequestra 
of  larger  or  smaller  size,  and  a  variable  amount  of  fluid,  made  up  of 
serum  and  leukocytes.  The  walls  of  this  cavity  are  formed  by 
tissues  in  which  the  disease  is  active;  the  inner  layer  containing 
the  tubercles  in  the  various  stages  of  formation  and  degeneration, 
the  outer,  composed  of  feeble,  ill-nourished,  granulation  tissue 
as  yet  not  infected,  and  beyond  this  the  softened  and  infiltrated 
bone.  If  the  disease  has  ceased  to  progress  in  any  direction  the 
granulations  contain  more  bloodvessels,  they  are  of  firmer  con- 
sistency and  more  perfectly  organized,  and  the  substance  of  the 
bone  is  harder,  showing  the  evidence  of  repair. 

One  termination  of  epiphysial  disease  is  by  enclosure  of  the 
focus  by  resistant  granulations,  behind  which  the  bone  solidifies 
and  shuts  in  the  disease,  or  in  favorable  cases  in  which  its  area  is 
small,  completely  absorbing  and  replacing  it  by  scar  tissue. 

Extra-articular  Disease. — ^As  a  rule  the  tendency  of  the  process 
is  to  expand  and  to  force  an  opening  through  the  cortex  of  the 
bone.  In  certain  cases  this  opening  may  form  beyond  the  capsule 
of  the  joint,  and  through  it  the  products  of  the  disease  may  be 
discharged  into  the  overlying  tissues,  forming  a  tuberculous  abscess. 
Here  the  same  process  of  infection  and  extension  of  the  area  of 
disease  continues,  but  more  rapidly  than  when  it  was  confined 
within  the  bone.  The  surfaces  of  the  muscles  and  fascia  are  infected, 
and  are  covered  with  an  abscess  membrane  of  violet  or  grayish- 


256        TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 

yellow  color,  made  up  of  tuberculous  tissue  and  masses  of  fibrin, 
l\'ing  upon  and  loosely  attached  to  the  outer  inflammatory  or 
healthy  granulations. 

The  tuberculous  fluid  is  usually  of  a  thin  consistency,  composed 
of  serous  exudation,  leukocytes,  fibrin,  masses  of  degenerated 
tissue,  and  fragments  of  bone  or  bone  sand.  It  is  commonly  of  a 
whitish  color,  occasionally  reddish  from  mixture  with  blood,  and 
in  the  later  stages,  yellow  and  serous-like.  The  abscess  enlarges 
in  the  direction  of  least  resistance,  and  in  most  instances  finally 
perforates  the  skin  by  one  or  more  openings  through  which  its 
contents  are  discharged.  Or  its  boundaries  may  cease  to  extend, 
its  contents  may  be  absorbed,  adhesions  may  form  between  its 
walls,  and  a  spontaneous  cure  is  effected.  Extra-articular  disease, 
without  ultimate  involvement  of  the  joint,  is  unusual.  It  is  more 
common  at  those  joints  like  the  knee,  elbow,  and  ankle,  in  which 
the  bones  are  superficial;  it  is  very  uncommon  at  the  hip-joint,  and 
it  is  practically  impossible  in  disease  of  the  spine. 

Perforation  of  the  Joint. — Usually  the  tuberculous  process  within 
the  epiphysis,  enlarging  its  area,  comes  into  contact  with  the  carti- 
lage, and  perforating  this,  finds  its  way  into  the  joint.  While  the 
disease  is  still  confined  within  the  bone,  the  tissues  within  the 
joint  are  involved  in  a  sympathetic  irritation  or  inflammation. 
The  synovial  membrane  becomes  congested  and  hypertrophied ; 
the  synovial  fluid  is  increased  and  changed  ni  quality;  fibrin  forms 
and  is  deposited  upon  the  cartilage  and  upon  the  lining  membrane 
of  the  capsule.  It  is  stated  by  Konig  that  the  organization  of  these 
fibrinous  deposits  upon  the  cartilage  plays  an  important  part  in 
its  destruction,  even  when  actual  tuberculous  disease  is  absent. 
As  a  result  of  the  sympathetic  inflammation  within  the  joint 
adhesions  may  form  which  may  limit  the  area  of  the  tuberculous 
disease  and  retard  its  progress  after  perforation  has  taken  place. 
This  process  is  similar  to  the  inflammatory  changes  in  the  pleura 
caused  by  underlying  tuberculous  disease  of  the  lung. 

^Yhen  the  disease  comes  into  contact  with  the  cartilage  it  disin- 
tegrates; the  tuberculous  granulations  breaking  through  and 
spreading  over  its  surface  destroy  it  piecemeal,  or  advancing 
beneath  it,  separate  it  from  the  bone  in  necrotic  fragments.  The 
synovial  membrane  becomes  thickened  and  infiltrated,  numerous 
tubercles  appear  upon  its  surface,  which  undergo  the  secondary 
changes  that  have  been  described,  and  the  joint  becomes,  practi- 
cally speaking,  an  abscess  cavity.  The  surfaces  of  the  bones  are 
disintegrated  by  the  disease,  and  the  destruction  is  hastened  by 
pressure  and  friction.  The  capsule,  distended  by  the  fluid  and 
solid  products  of  the  disease,  is  usually  perforated,  and  a  secondary 
abscess,  communicating  with  it,  is  formed  in  the  surrounding 
tissues.  As  results  of  the  disease,  secondary  changes  appear  in  the 
neighboring  parts.    The  irritation  of  the  periosteu'u  if  the  disease 


OTHER  FORMS  OF  TUBERCULOUS  DISEASE  OF  JOINTS    257 

is  of  a  quiescent  type,  may  induce  the  formation  of  irregular  layers 
of  bone  or  osteophytes  about  the  joint.  A  new  formation  of  con- 
nective tissue  proceeding  from  the  layer  of  granulations  that  sur- 
round the  disease  may  extend  to  the  muscles  and  tendon  sheaths, 
binding  them  together,  and  causing  limitation  of  motion.  This 
tissue  may  be  very  vascular  and  irregular  in  formation,  and  inter- 
mixed with  it  may  be  masses  of  gelatinous  or  myxomatous  sub- 
stance c^sed  apparently  by  the  venous  stasis  and  edematous  infil- 
tration induced  by  the  pressure  of  the  capsular  contents  and  extra- 
capsular proliferation  of  granulation  tissue.  These  changes  in  the 
appearance  and  in  the  consistency  of  the  tissues  about  the  joint 
are  characteristic  of  the  so-called  white  swelling. 

Tuberculous  disease  may  begin  on  the  epiphyseal  side  of  the 
conjugal  cartilage,  or  primarily  on  the  diaphyseal  side  and  remain 
extra-articular  or  the  shaft  may  be  involved  in  a  progressive  infil- 
trating form  of  disease  as  in  9  of  987  cases  treated  in  Bruns's  clinic.^ 
Of  this  the  most  familiar  example,  usually  multiple  in  its  distri- 
bution, is  "spina  ventosa" — a  central  disease  of  a  phalanx,  causing 
distortion  of  the  finger. 

Other  Forms  of  Tuberculous  Disease  of  Joints. — All  of  the 
German  writers  describe  forms  of  primary  synovial  disease,  its 
frequency  varying  from  16  to  35  per  cent,  of  the  cases.  It  is  more 
common  in  adult  life  than  in  childhood,  and  at  the  knee  than  at 
other  joints.  Nichols,^  on  the  other  hand,  states  that  he  has  exam- 
ined 120  tuberculous  joints,  and  has  found  in  every  instance  one 
or  more  foci  in  the  bone  that  apparently  preceded  the  disease  in 
the  joint.  This  is  certainly  not  in  accord  with  clinical  experience, 
for  one  must  recognize  a  form  of  disease  in  which  the  symptoms 
differ  from  the  ordinary  osteal  type.  It  begins  as  a  chronic  syno- 
vitis, although  the  tissues  are  more  thickened  and  infiltrated  than 
in  simple  synovitis,  and  the  muscular  atrophy  is  more  marked. 
Reflex  spasm  and  limitation  of  motion  are  slight,  and  the  symptoms 
are  rather  discomfort  and  fatigue  after  exertion  than  actual  pain. 
Later,  sometimes  after  many  months,  when  it  may  be  assumed  the 
bones  are  involved,  the  characteristic  symptoms  of  tuberculous 
disease  appear.  In  one  form  of  synovial  disease  the  amount  of 
effused  fluid  is  large,  and  it  is  clear  and  serous-like  in  character — 
hydrops  tuberculosis;  but  usually  it  is  cloudy,  and  it  may  be  puru- 
lent in  character. 

As  has  been  stated,  Konig  lays  stress  upon  the  important  part 
played  by  fibrin  in  the  changes  that  take  place  within  a  joint. 
Fibrin  deposited  from  the  effused  fluid  forms  in  successive  layers 
upon  the  cartilage.  Into  this  fibrin  vessels  grow  from  the  hyper- 
trophied  and  infected  synovial  membrane,  destroying  the  cartilage 
together  with  the  underlying  bone.    If  the  synovial  disease  is  pri- 

1  Zumsteeg:  Beitr.  z.  klin.  Chir.,  1906,  Band  1,  Heft  1. 

2  Tr;  Am.  Orthop.  Assn.,  xi. 
17 


258        TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 

mary  the  erosion  of  bone  is  superficial  as  contrasted  with  the  ordi- 
nary osteal  t}"pe.  Synovial  tuberculosis  is  essentially  a  subacute 
chronic  affection  and  it  is  therefore  often  mistaken  for  traumatic 
or  so-called  rheumatic  synovitis. 

Arborescent  Synovial  Tuber culosis.^ — In  this  form  the  interior  of 
the  joint  is  covered  with  villous  proliferations  of  the  synovial 
membrane.  It  is  not  a  distinct  disease,  but  is  an  irritative  hyper- 
trophy that  is  present  in  s}-philitic  and  rheumatic  as  well  as  in 
tuberculous  joints.  Its  especial  interest  hes  in  the  fact  that  the 
hypertrophied  synovial  growths  may  cause  mechanical  interference 
with  the  function  of  the  joint. 

Arborescent  villous  proliferations  are  formed  of  adipose  and 
fibrous  tissue  covered  with  a  layer  of  round  cells.  The  hj^er- 
trophied  masses  which  project  into  the  joint  are  often  of  large  size 
(lipoma  arborescens),  attached  to  the  synovial  membrane  by  a 
smaller  pedicle.     They  are  single  or  multiple,  and  vary  in  color 


Fig.  209. — Lipoma  arborescens.      (Painte^"and]E^^^ng.) 

from  yellow  to  deep  red.  They  may  be  of  a  soft  or  firm  consistency. 
In  this  form  of  disease  there  is  usually  pain,  limitation  of  motion; 
often  the  swollen  joint  is  irregular  in  outline;  the  hj'pertrophied 
synovial  prolongations  are  sometimes  apparent  on  palpation.^  The 
exact  diagnosis  is  usually  made  only  after  an  exploratory  incision, 
and  in  such  an  event  the  removal  of  the  larger  growths  would  be 
indicated.  The  outcome  depends,  of  course,  upon  the  cause,  the 
hypertrophy  depending  usually  on  an  underlying  tuberculous, 
syphilitic,  or  other  chronic  disease.  In  the  instances  in  which  the 
hypertrophied  tissue  is  in  itself  the  cause  of  the  disability  by  inter- 
ference with  function,  relief  may  follow^  its  removal. 

Rice  Bodies. — Rice  bodies  are  small,  grayish-white  bodies  resem- 
bling cucumber  seeds  that  are  found  in  certain  forms  of  synovial 

1  Painter  and  Ening:  Boston  Med.  and  Surg.  Jo\ir.,  March  19,  1903. 


OTHER  FORMS  OF  TUBERCULOUS  DISEASE  OF  JOINTS     259 

disease,  and  particularly  in  tuberculosis  of  tendon  sheaths.  They 
are  formed  of  fragments  detached  from  the  proliferating  synovial 
membrane  and  possibly  of  simple  fibrin,  which,  under  the  influence 
of  pressure  and  attrition  in  the  movements  of  the  joint  or  of  the 
tendon,  assume  the ,  characteristic  shape  and  appearance.  These 
bodies,  within  a  tendon  sheath  or  joint,  cause  a  peculiar  creaking, 
perceptible  to  the  touch  when  the  part  is  moved. 

Dry  Caties  {Caries  Sicca). — In  this  form  of  disease,  which  is 
apparently  primarily  synovial,  there  is  but  little  formation  of  fluid, 
and  but  little  tendency  toward  cheesy  degeneration  of  the  tuber- 
culous products.  The  infected  granulations  destroy  the  bone 
without  forming  sequestra,  and  usually  without  suppuration.  This 
form  more  often  occurs  at  the  shoulder-joint,  and  it  is  characterized 
by  marked  limitation  of  motion,  extreme  atrophy  of  the  surround- 
ing parts,  and  sometimes  by  forward  displacement  of  the  partly 
destroyed  head  of  the  humerus  that  may  be  mistaken  for  a  primary 
dislocation. 

Tuberculous  Rheumatism. — ^According  to  Poncet^  chronic  poly- 
arthritis in  tuberculous  subjects  is  often  caused  by  toxines  or 
attenuated  forms  of  bacilli.  It  may  be  acute  in  character,  or  resem- 
bling the  ordinary  forms  of  so-called  rheumatoid  arthritis.^ 

Septic  Infection. — After  a  tuberculous  abscess  has  opened  spon- 
taneously, or  if  it  has  been  incised,  infection  with  pyogenic  germs 
is  common,  and  it  occasionally  occurs  before  a  communication  with 
the  exterior  has  been  established. 

After  such  infection  the  surrounding  tissues  become  infiltrated, 
reddened,  and  sensitive  to  pressure.  The  discharge  is  greatly 
increased  in  quantity  and  changed  in  quality.  The  local  pain  and 
discomfort  are  aggravated;  if  the  joint  is  involved  the  destruction 
of  the  bone  goes  on  with  increased  rapidity,  and  the  constitutional 
effects  of  pyogenic  infection  appear.  If  the  area  of  the  abscess  is 
small  and  if  the  drainage  is  efficient,  this  accident  is  of  slight  impor- 
tance, and  it  may  even  exercise  a  beneficial  effect  in  stimulating 
the  circulation  and  dissolving  the  effused  material  about  a  joint. 
But  if  the  abscess  has  burrowed  widely  into  surrounding  tissues 
and  if  it  communicates  with  an  important  joint  it  is  a  dangerous 
complication;,  in  fact  the  greatest  direct  danger  of  tuberculous 
joint  disease.  Persistent  suppuration  exhausts  the  patient,  and 
by  lessening  the  vital  resistance  it  favors  the  local  advance  of  the 
tuberculous  disease  and  its  general  dissemination.  It  is  in  this 
class  of  cases  that  amyloid  degeneration  of  the  internal  organs  is 
common,  induced  not  by  tuberculous  disease,  but  by  the  secondary 
infection  and  its  consequences. 

Repair. — Repair  in  tuberculous  disease  may  be  accomplished 
by  the   absorption,   ejection,   or  enclosure   of  the   disease.     The 

1  Bull,  et  Mem.  de  la  Soc.  Med.  des  Hop.  de  Paris,  1909,  Ixviii. 

2  Lyle:  Ann.  Surg.,  March,  1912. 


260        TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 

process  of  repair  usually  accompanies  the  advance  of  the  destruc- 
tive process,  and  examples  of  the  three  methods  of  cure  may  be 
found  in  a  single  joint. 

The  curative  agent  is  the  granulation  tissue  which  forms  about 
the  area  of  disease,  and  which,  finally  becoming  sufficiently  organ- 
ized to  resist  the  infection  of  the  bacilli,  solidifies  into  fibrous  tissue. 
In  those  cases  in  which  the  disease  is  not  absorbed  or  completely 
thrown  oft'  in  the  abscess  formation,  but  is  enclosed,  it  becomes 
quiescent.  In  such  cases  injiu-y,  when,  for  example,  the  surrounding 
adhesions  are  broken  down  in  the  attempt  to  correct  deformity  or 
to  overcome  anchylosis,  may  cause  local  recurrence  of  the  disease. 

Prognosis. — The  prognosis  will  be  considered  more  particularly 
in  the  sections  on  disease  of  special  parts.  The  danger  to  life  is 
direct  and  indirect,  and  this  varies  greatly  with  the  part  that  is 
affected  and  with  the  age  of  the  patient. 

In  disease  of  the  spine  the  direct  danger  to  life  is  greater  than  in 
joint  disease,  because  of  its  situation,  since  it  may  involve  the 
spinal  cord  or  extend  to  the  important  organs  in  the  neighborhood. 
Abscess  may  in  rare  instances,  merely  by  its  size  and  situation, 
endanger  life,  and  when  infected  it  is  far  more  dangerous  because 
of  the  difficulty  in  providing  efficient  drainage.  The  influence  of 
deformity  and  its  effect  in  compressing  the  internal  organs  and  thus 
interfering  t\  ith  the  vital  fiuictions  is  another  more  remote  element 
of  danger  in  disease  in  this  situation. 

The  danger  to  life  from  disease  of  the  joints  is  in  proportion  to 
their  importance.  In  rare  instances  the  disease  may  extend  from 
the  epiphysis  to  the  shaft  of  a  bone  and  set  up  an  extensive  osteo- 
myelitis; or  the  patient  may  be  weakened  by  the  suffering  caused 
by  active  disease,  but,  as  has  been  stated,  the  most  direct  and 
constant  danger  is  from  prolonged  suppm-ation  that  follows  septic 
infection.  Danger  from  this  source  is  much  greater  at  the  hip- 
joint  than  at  the  ankle  or  elbow,  for  example,  because  of  the  greater 
difficulty  in  preventing  the  burrowing  of  pus  when  infection  has 
occurred. 

The  indirect  danger  of  tuberculous  disease  is  its  dissemination 
to  more  important  organs.  But  it  by  no  means  follows  that  the 
disease  of  the  joint  is  the  source  of  the  general  infection.  For,  as 
has  been  stated,  it  may  be  inferred  that  nearly  every  patient  with 
joint  disease  has  also  disease  of  the  hTaphatic  glands,  and  in  a 
certain  proportion  of  the  cases  there  may  be  active  disease  of  other 
important  organs  as  well.  Tuberculosis  of  the  lungs,  for  example, 
is  often  present  in  the  adult  before  the  local  outbreak  in  the  joint 
appears,  and  it  is  in  great  degree  because  of  this  liability  to  disease 
of  the  lungs  that  the  prognosis  of  joint  disease  becomes  progressively 
worse  with  the  age  of  the  patient. 

This  point  is  illustrated  by  the  statistics  of  Konig  and  Bruns 
on  the  final  results  of  disease  of  the  knee-  and  hip-joints,  to  which 


PROGNOSIS  2C1 

attention  will  be  called  again  in  the  special  sections.  In  Konig's 
cases  of  disease  of  the  knee-joint  the  influence  of  age  upon  the 
death-rate  is  presented  in  the  following  table: 

Less  than  15  years  of  age 20  per  cent. 

From  16  to  30  years 24 

From  30  to  40  years 44  " 

More  than  40  years 60  " 

In  Bruns's  statistics  the  death-rate  was  of  patients  in  the  first 
decade,  36  per  cent.;  in  the  second  decade,  44  per  cent.;  older  than 
this,  72  per  cent. 

In  but  6  of  900  children  under  treatment  for  hip  disease  by 
Bowlby  were  the  lungs  involved. 

The  cure  of  latent  tuberculosis  in  the  lymph  nodes  as  well  as 
of  active  disease  of  the  lungs  or  bones  depends  upon  the  vital 
resistance  of  the  patient.  This  vital  resistance  is  lessened  by  pain, 
by  confinement  and  lack  of  exercise.  It  is  directly  impaired  by 
the  exhausting  suppuration  and  by  the  poisoning  of  the  toxins 
incidental  to  septic  infection.  Under  these  conditions  the  local 
disease  advances  and  a  general  dissemmination  is  more  probable. 
This  accounts  for  the  fact  that  death  from  general  tuberculous 
infection  is  far  more  common  in  this  class  th^n  when  suppuration 
has  been  slight  or  absent.  This  point  is  again  illustrated  by  the 
statistics  referred  to.  The  death-rate  in  the  cases  of  disease  at 
the  knee  without  abscess  was  25  per  cent.,  with  abscess  46  per 
cent.  Death-rate  in  cases  of  disease  at  the  hip  with  abscess  52 
per  cent.,  without  abscess  23  per  cent. 

It  is  probable  that  tuberculosis  may  be  disseminated  by  opera- 
tion upon  tuberculous  joints,  although  the  evidence  upon  this  point 
is  vague  and  conflicting.  Gibney,  contrasting  two  equal  periods 
of  thirteen  years  of  service  at  the  Hospital  for  Ruptured  and 
Crippled,  in  the  first  of  which  no  operations  were  performed  on 
tuberculous  subjects,  states  that  in  his  opinion  the  deaths  from 
this  source  have  been  proportionately  no  greater  during  the  period 
of  active  surgical  intervention  than  before.  An  investigation  of 
the  causes  of  deaths  among  the  patients  treated  at  the  New  York 
Orthopedic  Dispensary  and  Hospital  during  a  period  of  twenty 
years  showed  that  at  least  25  per  cent,  of  these  were  due  to  tuber- 
culous meningitis.^  During  this  period  there  had  been,  practically 
speaking,  no  operative  intervention,  yet  the  proportion  of  deaths 
from  this  cause  is  certainly  as  great  as  in  any  statistics  that  have 
been  reported.  It  would  appear,  then,  that  the  danger  of  dissemi- 
nation is  not  sufficient  to  deter  one  from  performing  any  operation 
that  seems  to  be  indicated  by  the  character  of  the  local  disease 
or  by  the  general  condition  of  the  patient. 

1  Personal  communication  from  Dr.  David  Bovaird. 


262        TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 

Diagnosis. — Diagnosis  is  considered  at  length  in  the  sections 
on  diseases  of  the  special  joints.  Of  the  tuberculin  tests  the  direct 
injection  is  the  most  reliable.  This  is  valuable  from  the  negative 
stand-point,  but  less  so  as  establishing  a  diagnosis  of  joint  disease, 
for  the  reason  that  tuberculous  disease  of  the  lymph  glands  or  else- 
where is  so  common  even  among  those  whose  joints  are  free  from 
disease.  According  to  Northman,  77  per  cent,  of  children  between 
three  and  seventeen  years  react  and  100  per  cent,  of  those  between 
fifteen  and  seventeen  years.  Of  532  children  tested  by  Hamberger^ 
271  reacted  positively.  Of  those  in  the  first  year  of  life  but  2  per 
cent,  reacted  as  compared  with  94  per  cent,  between  eleven  and 
fourteen  years.  For  the  same  reason  it  is  valueless  as  a  test  of 
practical  cure.  This  is  illustrated  by  the  investigations  of  Frazier 
and  Biggs^  of  patients  clinically  cured  of  local  tuberculosis,  some 
by  operative  means.  In  78  per  cent,  of  these  a  positive  reaction 
to  tuberculin  was  obtained.  In  some  instances,  however,  a  local 
reaction  may  indicate  foci  of  disease  whose  presence  would  not 
otherwise  have  been  suspected. 

Tinker,  who  has  reported  a  series  of  four  hundred  tests  from 
Johns  Hopkins  Hospital,  states  that  healthy  individuals  react  if 
the  dose  is  sufficiently  large.  One  therefore  begins  with  small 
injections,  from  1  to  3  mgm.  of  Koch's  old  tuberculin.  This  may 
be  increased  to  9  mgm.,  a  reaction  to  less  than  this  amount  being 
practicafiy  positive  if  the  temperature  of  the  patient  taken  at 
intervals  of  two  hours  for  at  least  eighteen  hours  has  been  normal. 
The  reaction  appears  in  from  six  to  eight  hours. 

The  a:-rays  are  often  of  value  in  demonstrating  the  eftects  of  dis- 
ease, and  in  certain  instances  it  may  indicate  its  exact  locality  and 
extent.  As  a  means  of  early  diagnosis  of  joint  disease  in  young 
subjects,  however,  it  is  of  little  importance  as  compared  to  the 
physical  signs,  because  of  the  non-development  of  the  bony 
structure  of  the  epiphysis,  which  alone  appears  in  the  negative. 

Treatment. — From  what  has  been  stated  of  the  causes  of  dis- 
ease it  follows  that  the  general  treatment  should  include,  if  pos- 
sible, an  improvement  of  the  hygienic  conditions,  relief  from  the 
danger  of  further  infection,  pure  air,  and  proper  food.  These  are 
as  essential  in  the  treatment  of  tuberculosis  of  the  bones  as  of  other 
parts. 

The  importance  of  the  constitutional  treatment  of  tuberculous 
disease,  more  particularly  the  proper  environment  in  which  the 
greater  part  of  the  day  and  even  the  night  may  be  passed  in  the 
open  air,  can  hardly  be  exaggerated. 

Direct  Sunlight. — In  1903  Rollier^  at  Leydin  near  Geneva,  began 
the  treatment  of  surgical  tuberculosis  by  direct  exposure  of  the 

1  British  Med.  Jour,  July  9,  1910. 

2  Univ.  Med.  Mag.,  February,  1901. 

3  New  York   Med.   Jour.,   June,    1915. 


TUB  AT  MEN  f  26S 

body  to  sunlight,  a  practice  that  in  a  modified  form  has  been 
generally  adopted.  The  details  of  the  treatment  as  conducted  by 
Rollier  are  summarized  by  Pryor  as  follows: 

Certain  steps  are  very  important  and  can  be  presented  briefly. 
The  insolation  is  very  gradual  and  slowly  completed.  The  dis- 
eased part  is  kept  covered  and  only  exposed  to  the  sun  after  the 
coat  of  tan  is  existent  over  the  remainder  of  the  body.  The  patient 
is  made  accustomed  to  open-air  life  and  sleeping  out  of  doors  for 
about  one  week.  During  this  period  the  temperature,  respiration  and 
pulse,  and  the  results  of  the  urine  and  blood  examinations  are  recorded. 

First  Day. — Preparation  for  the  sun  bath  includes  protection 
from  wind  or  draft.  The  head  is  protected  by  a  linen  cap  or  a 
small  awning  at  the  head  of  the  bed,  and  the  eyes  shaded  by  colored 
glasses  or  covered  with  a  towel.  Then  the  patient's  feet  are  exposed 
to  the  direct  sun's  rays  for  five  to  ten  minutes  three  or  four  times  a 
day  at  hour  intervals. 

Second  Day. — ^The  feet  are  insolated  ten  minutes,  the  legs  from 
the  ankles  to  knees  five  minutes  three  or  four  times  at  hour  intervals. 

Third  Day. — The  feet  are  insolated  fifteen  minutes,  the  legs 
from  the  ankles  to  the  knees  ten  minutes,  and  the  thighs  five  min- 
utes three  or  four  times  at  hour  intervals. 

Fourth  Day. — The  insolation  of  the  previously  exposed  parts  is 
increased  by  five  minutes  three  or  four  times  a  day  at  hour  intervals. 

Fifth  Day. — Again  the  insolation  of  the  previously  exposed  parts 
is  increased  by  five  minutes  and  the  chest  is  exposed  five  minutes 
three  or  four  times  at  hour  intervals. 

Sixth  Day. — ^The  exposure  of  the  previously  insolated  parts  is 
again  increased  five  minutes  and  the  neck  and  head  are  exposed 
five  minutes  three  or  four  times  at  hour  intervals. 

Seventh  Day. — If  all  conditions  allow  the  patient  is  turned  on 
his  abdomen  and  the  same  course  as  described  repeated. 

Gradually  the  whole  body  and  finally  the  diseased  part  is  exposed 
and  tanned  as  deeply  as  possible.  After  each  insolation  the  patient 
is  rubbed  with  spirits  of  camphor  with  a  rough  glove.  Ultimately  in 
the  course  of  weeks  the  insolation  is  practised  from  four  to  six 
hours  a  day.  This  treatment  is  all  carried  out  on  the  bed  to  secure 
convenience  and  control.  Caution  must  be  observed  to  prevent 
sunburns  and  dermatitis.  These  accidents  can  be  entirely  avoided 
with  practise.  Reactions  may  occur  if  the  exposure  is  pushed  too 
rapidly,  and  the  condition  of  the  individual  must  be  considered 
particularly  if  fever  is  present.  When  the  children  are  hardened 
by  exposure  an  air  bath  is  given  on  cloudy  days  to  maintain  it. 
During  the  summer  the  children,  well-tanned,  can  play  or  walk 
about  most  of  the  day  unclothed  except  for  a  loin  cloth.  The 
patient  gradually  acquires  a  generous  coat  of  tan,  and  the  skin  has 
a  bronze  hue,  then  a  copper  color  and  finally  the  desired  chocolate 
brown  appears  to  signify  intensive  pigmentation. 


264       TUBERCULOUS  DISEASE  OF  BONES  AND  JOINTS 

It  is  assumed  that  the  direct  effect  of  the  sunhght  is  to  increase 
metaboKsm  and  to  raise  the  hemoglobin  index.  Locally  it  exer- 
cises a  bactericidal  influence,  the  ultraviolet  rays,  according  to 
Rollier,  being  of  the  first  importance.  According  to  Bardenheuer,^ 
of  371  cases  treated  by  Rollier  78  per  cent,  were  cured,  13  per  cent, 
improved,  6  per  cent,  were  still  under  treatment,  the  mortality 
being  4  per  cent.  There  was  practically  no  surgical  intervention. 
If  plaster  was  used  openings  were  made  for  the  direct  application 
of  the  sunlight.  In  Pott's  disease  both  the  kyphosis  and  the  abdo- 
men are  exposed  for  the  purpose.  Abscesses  and  suppurating 
diseases  received  no  other  treatment. 

Operative  Treatment. — As  far  as  the  cure  of  local  disease  is  con- 
cerned, no  treatment  can  be  as  effective  as  the  prompt  and  thorough 
removal  of  the  focus  of  disease,  while  it  is  yet  limited  in  extent,  and 
before  the  joint  has  become  involved.  This  is  practicable,  however, 
in  but  a  small  proportion  of  the  cases  in  childhood,  because  it  is 
usually  impossible  to  locate  the  disease  accurately  and  impossible  to 
remove  it  without  sacrificing  normal  bone  upon  which  the  future 
usefulness  of  the  part  depends.  At  one  time  early  operation,  even 
complete  excision  of  the  joint,  was  justified  on  the  plea  that  the 
disease  might  thus  be  eradicated.  But  now  that  it  is  known  that 
in  nearly  all  cases  other  tuberculous  foci  exist  in  the  body,  and  as 
the  functional  results  after  these  early  operations  are  far  inferior 
to  those  attained  under  conservative  treatment,  early  excisions 
are  limited  to  the  adolescent  or  adult  cases.  For  in  this  class  growth 
has  been  attained  and  the  economic  conditions  require  that  the 
period  of  disability  should  be  as  short  as  possible.  In  this  class, 
also,  early  exploratory  operations  are  often  indicated,  sometimes 
for  the  purpose  of  establishing  the  diagnosis,  and  if  the  disease  is 
of  the  synovial  type  the  removal  of  projecting  folds  of  hypertro- 
phied  tissue  and  the  direct  application  of  irritants,  for  example, 
of  pure  carbolic  acid  or  iodin,  may  be  of  service. 

Mechanical  Treatment. — Brace  treatment  is  conducted  with  the 
aim  of  relieving  the  part  of  function — that  is  to  say,  from  strain  and 
injury.  Functional  use  of  a  diseased  joint  delays  natural  repair, 
since  it  causes  pain  and  thus  reduces  the  reparative  force,  while  it 
stimulates  the  disease  and  increases  its  destructive  action.  The 
details  of  treatment  will  be  described  in  the  consideration  of  disease 
of  special  joints. 

Drugs. — The  administration  of  drugs  occupies  a  very  subordinate 
place  in  treatment,  since  it  is  not  believed  that  any  drug  exercises 
a  direct  action  upon  the  local  disease  in  the  bone. 

Cod-liver  oil,  the  h^^Dophosphites,  the  various  preparations  of 
iron  or  other  tonics  may  be  given  at  certain  times  with  benefit, 
but  the  continuous  administration  of  medicine  during  the  years  that 
are  required  to  complete  a  cure  is,  of  course,  out  of  the  question. 

1  Deutsch.  Ztschr.  f.  Chir.,  cxii. 


TREATMENT  265 

Local  Applications. — Iodoform. — Iodoform  is  supposed  to  exer- 
cise a  direct  germicidal  action,  and  also  to  stimulate  the  formation 
of  the  granulations  that  cast  off  or  absorb  the  tuberculous  products 
and  then  become  transformed  into  fibrous  tissue.  Its  use  is  now  prac- 
tically limited  to  the  treatment  of  tuberculous  abscesses  and  certain 
forms  of  synovial  tuberculosis.  Iodoform  is  ordinarily  employed  in 
an  emulsion  with  glycerin  or  oil,  10  c.c.  of  10  per  cent,  mixture  being 
injected  at  intervals  of  two  or  more  weeks  after  aspiration.  Several 
deaths  from  iodoform  poisoning  have  been  reported,  but  injections 
of  this  quantity  of  the  drug  are  apparently  free  from  danger. 

Calot's  Fluids} — These  mixtures  are  interchangeable,  but  the  first 
is  preferred  if  the  contents  of  the  abscess  are  liquid  ("ripe"),  the 
second  when  the  products  of  disease  are  but  partly  broken  down. 
The  dose  of  each  is  from  2  to  12  gm.  repeated  at  intervals  of  a  week 
or  more;  10  or  more  injections  being  employed  in  the  treatment  of 
the  ordinary  case.     (See  Pott's  Disease.) 

Iodoform  Filling  for  Bone  Cavities  (V.  Mosetig-Moorhof^). — 
Equal  parts  of  spermaceti  and  oil  of  sesame  are  sterilized  on  a 
water-bath  and  are  mixed  with  finely  powdered  iodoform  in  a 
proportion  of  60  to  40  of  the  drug,  making  a  yellow  brittle  wax 
melting  at  50°  C.  When  used  it  is  heated  just  above  the  melting- 
point  and  constantly  stirred.  The  cavity  in  the  bone,  having  been 
made  absolutely  dry,  is  filled  with  the  fluid,  which  solidifies  as  the 
temperature  is  lowered.  The  wound  is  then  closed.  The  filling  is 
slowly  absorbed,  its  object  being  to  preserve  the  contour  of  the 
bone.  In  a  series  of  220  cases  reported  by  this  author  no  local 
disturbance  followed  the  procedure. 

Beck's  Preparation. — E.  G.  Beck  originally  used  for  injection, 
bismuth  and  vaseline  in  proportion  of  1  to  3.  The  mixture  is 
made  while  the  vaseline  is  boiling  and  is  injected  at  a  temperature 
of  110°.  The  abscess  is  evacuated  by  aspiration  and  a  sufficient 
quantity  is  injected  to  distend  the  abscess  cavity  and  thus  to  exer- 
cise a  certain  degree  of  mechanical  pressure.  In  the  process  of 
absorption  it  is  assumed  that  nitric  acid  is  set  free  and  that  a  germi- 
cidal action  is  thus  exerted.  To  fill  the  abscess  cavity  a  large 
quantity  of  the  mixture  may  be  required  and  the  injection  must 
be  repeated  at  intervals.  Many  cases  of  poisoning  of  a  mild  type 
have  been  recorded  and  several  deaths — one  from  the  injection  of 
as  small  an  amount  as  six  ounces.  Consequently  the  proportion  of 
bismuth  has  now  been  reduced  to  10  per  cent.  The  symptoms  of 
poisoning  are  headache,  vomiting,  loss  of  strength,  livid  color, 
ulceration  of  the  gums,  etc. 


1  Calot's 

fluids  for  injection. 

_  No.  1. 

No.  2. 

Guiacol         1  gm. 

Camphorated  napthol 

2gm 

Creosote       5    " 

Glycerin 

12    " 

Iodoform    30    " 

Shake  before  injecting. 

Ether           30    " 

Oil                70    " 

2  Deutsch.   Ztschr.  f.   Chir.,  Ixxi,   No.    5. 


266        TUBERCULOUS  DISEASE  OF  BOXES  AND  JOINTS 

It  is  now  generally  held  that  the  chief  curative  influence  of  these 
injections  is  mechanical,  i.  e.,  the  removal  of  pus,  the  exclusion  of 
air  and  pressure  on  the  granulation  tissue;  consequently,  that  non- 
toxic preparations  are  equally  efficaceous.  Blanchard/  uses  white 
wax  1  part,  vaseline  8  parts  mixed  while  boiling,  or  in  badly 
infected  cases,  iodin  scales  are  mixed  with  the  paste.  After  the 
injection  a  pad  saturated  in  alcohol  is  bound  over  the  sinus  to 
prevent  the  escape  of  the  fluid. 

Of  150  cases  reported  35  per  cent,  were  cured  by  from  1  to  8 
treatments.  Thkty  per  cent,  were  cured  in  a  year,  and  35  per  cent, 
remained  unimproved. 

Blanchard  concludes  that  cases  with  sequestra,  or  those  in  which 
free  drainage  is  required,  or  those  in  which  the  sinus  is  newly 
formed,  should  not  be  treated  by  this  method,  but  that  clironic 
cases  in  which  the  discharge  is  small  and  semipurulent  are  often 
greatly  benefited  by  it. 

Beck's  mixture  was  originally  used  for  the  purpose  of  demon- 
strating the  situation  and  extent  of  abscesses  and  sinuses  by  .r-ray 
pictures  and  for  this  purpose  it  is  of  value  aside  from  its  therapeutic 
action.     (See  Sinuses.) 

Carbolic  Acid. — Carbolic  acid  in  dilute  solutions  was  at  one 
time  injected  into  tuberculous  cavities,  but  its  use  has  been  gener- 
all;si  discontinued  because  of  the  danger  of  poisoning.  Pure  car- 
bolic acid  may  be  injected  into  the  fistulse  or  into  the  abscess  cav- 
ity which  has  been  opened;  it  is  allowed  to  remain  for  about  a 
minute,  when  it  is  neutralized  by  copious  injections  of  alcohol, 
after  which  the  part  is  thoroughly  cleansed  by  salt  solution.  Car- 
bolic acid  doubtless  acts  as  a  caustic,  destro^dng  the  infected  granu- 
lations and  stimulating  the  reparative  processes.  Other  remedies 
of  this  class,  for  example  tinctiue  of  iodin,  chloride  of  zinc,  actual 
cautery  and  the  like,  are  also  used,  and  in  certain  cases  with  bene- 
fit. In  the  treatment  of  tuberculous  ulcerations  ichthyol,  balsam 
of  Peru,  and  iodoform  are  among  the  drugs  employed.  Balsam  of 
Peru  dissolved  in  castor  oil  of  a  strength  of  about  10  per  cent.,  as 
suggested  by  Van  Arsdale,-  is  a  very  satisfactory  application. 

X-rays. — ^The  .r-rays  as  a  local  treatment  appear  to  act  as  a  stim- 
ulant of  the  reparative  processes.  It  is  of  especial  value  as  an 
adjunct  in  the  cases  in  which  the  tissues  about  the  joint  are  infil- 
trated and  traversed  by  discharging  sinuses.  The  so-caUed  Alpine 
light  appears  to  exert  a  similar  influence. 

Active  and  Passive  Congestion  (Bier's  Hyperemia). — Bier's  treat- 
ment of  tuberculous  joint  disease  was  suggested  by  the  observation 
of  Rokitansky,  that  phthisis  was  uncommon  in  individuals  sufl'er- 
ing  from  disease  of  the  heart  when  the  mechanical  obstruction  was 
sufficient  to  cause  venous  congestion  of  the  lungs. 

1  Med.  Rec,  May  18,  1912. 

2  Jour.  Am.  Med.  Assn.,  March  1-4,  1908. 


TREATMENT 


267 


Passive  Congestion. — Passive  or  venous  congestion  of  a  joint 
is  attained  by  constricting  the  limb  with  several  circular  turns  of 
a  soft-rubber  bandage  above  the  affected  joint  sufficiently  to 
interfere  with  the  return  of  the  venous  blood,  but  not  with  the 
arterial  supply. 


Fig.  210. — The  application  of  passive 
congestion:  A,  the  alternate  point  for 
the  application  of  the  bandage,  in  order 
to  avoid  atrophy  from  continuous  pres- 
sure.    B,  the  rubber  bandage.     (Bier.) 


Fig.  211. — The  alcohol  lamp  and 
chimney.  Used  for  active  congestion. 
(Bier.) 


.  The  congestion  may  be  localized  if  desirable  by  bandaging  the 
limb  firmly  with  flannel  or  other  somewhat  elastic  material  up  to 
the  lower  margin  of  the  joint.  This,  however,  is  not  essential  and 
in  treating  disease  of  an  extremity  in  which  the  other  joints  are 
stiffened  or  in  which  the  muscles  are  atrophied  and  contracted, 
the  congestion  of  the  entire  limb  is  indicated.  When  properly 
applied  the  joint  becomes  swollen  and  dark  red  in  color.    The  local 


268        TUBERCULOUS  DISEASE  OF  BOXES  AXD  JOINTS 

temperature  is  raised.  This  is  what  Bier  calls  hot  congestion,  as 
distinct  from  edema  (cold  congestion),  that  would  result  if  the  rub- 
ber bandage  were  applied  so  tight  as  to  constrict  the  arteries. 
Passive  congestion  should  not  cause  or  increase  pain.  If  it  has 
this  effect  it  is  improperh*  applied  or  is  unsuitable  for  the  case 
(Fig.  210). 

The  application  should  be  limited  to  one  to  tlu-ee  hours  daily 
in  one  or  several  periods,  according  to  the  effects.^ 

The  action  of  the  venous  or  passive  congestion  is,  according  to 
Bier,  as  follows : 

1.  It  increases  the  formation  of  fibrous  tissue  and  induces 
h\'pertrophy  of  the  bones. 

2.  It  has  a  bactericidal  action  in  infectious  joint  disease,  notably 
tuberculosis.- 

3.  It  exercises  an  absorptive  effect  on  the  eff'used  products  of 
disease  and  on  new  formations  that  check  joint  motion. 

-1.  It  relieves  pain  and  lessens  the  activity  of  progressive  joint 
disease. 

Passive  congestion  for  tubercidous  joint  disease  should  be  an 
adjunct  to  protective  treatment,  although  this  is  not  the  opinion 
of  Bier,  who  favors  motion  rather  than  fixation  of  the  diseased 
joint.  It  may  be  continued  indefinitely  according  to  its  effect. 
As  a  rule  pain  is  lessened  by  the  treatment  and  muscular  spasm 
decreases  during  its  apphcation,  an  effect  explained  apparently  by 
the  constriction  of  the  muscles. 

Abscess  formation  or  appearance  at  least  is  apparently  favored 
by  the  congestion.  This  may  be  treated  by  aspiration  or  incision 
and  by  injection  as  may  seem  desirable. 

Passive  congestion  is  employed  also  for  the  treatment  of  cln*onic 
disability  following  injury,  for  chronic  arthritis  or  other  affection 
attended  by  infiltration  of  tissues  and  by  deficient  chculation.  In 
this  class  of  cases  the  local  congestion  should  be  combined  with 
massage.  Local  congestion  may  be  attained  by  Klapp's  suction 
appliances  on  the  principle  of  cupping.  This  method  may  be 
employed  with  advantage  in  the  treatment  of  sinuses  and  cavities 
which  cannot  be  properly  drained  and  for  the  immediate  evacuation 
of  pus  through  a  small  incision. 

Active  Coxgestiox. — Active  congestion  is  induced  by  the  local 
use  of  heat,  ordinarily  hot,  dry  air. 

In  its  simplest  form  the  apparatus  consists  of  an  alcohol  lamp 
provided  with  a  long  metal  chimney  reaching  to  a  box  of  wood  or 
metal,  into  which  the  limb  is  inserted  through  openings  at  either 
end.  The  box  has  one  or  more  smah  openings  for  the  escape  of 
air  and  moisture.    The  limb  is  usually  wrapped  in  sheet  wadding, 

1  Bier:  Hyperiimie  als  Heilmittel,  Leipzig,  1905,  and  Schmieden,  Med.  Rec, 
August  17,  1907. 

-  Gratt:  Berlin,  klin.  Wchnschr.,  February  10,  1908. 


TREATMENT 


269 


and  is  particularly  well  protected  from  the  parts  of  the  box  which 
may  come  in  contact  with  the  skin.  The  heat  is  then  applied, 
usually  to  about  250°  to  300°  F.,  for  from  thirty  minutes  to  an 
hour  daily.  The  degree  of  heat  is  indicated  by  a  projecting  ther- 
mometer, and  it  is  regulated  by  the  comfort  of  the  patient  and  by 
the  observation  of  its  effects. 

Bier  prefers  simple  boxes  of  wood  of  various  shapes  suitable  for 
the  different  parts  of  the  body,  lined  with  packing  cloth  soaked  in 
a  solution  of  water  glass.  He  considers  these  as  efficacious  as  the 
complicated  and  expensive  appliances,  and  at  the  command  of  all 
who  desire  to  employ  the  treatment  (Fig.  212). 


Fig.  212. — The  application  of  the  hot-air  box  for  inducing  active  congestion: 
C,  the  thermometer;  A,  a  metal  pipe  projecting  from  the  box,  into  which  the 
chimney  of  the  lamp  is  placed;    S,  lamp  chimney.     (After  Bier.) 


The  effect  of  the  heat  is  to  induce  arterial  instead  of  venous 
hyperemia,  and  to  cause  profuse  local  and  often  general  perspira- 
tion. Active  hyperemia  is  not  suitable  for  the  treatment  of  acute 
or  progressive  joint  disease.  It  exercises  a  dissolving  and  absorbing 
action  on  effused  material  and  on  the  tissues  of  new  formation, 
causing  limitation  of  motion  within  a  joint.  It  increases  local 
nutrition  and  it  relieves  pain.  It  is  especially  indicated  in  the  treat- 
ment of  local  disability  after  injury,  chronic  effusions  into  joints, 
chronic  arthritis,  and  the  like  in  which  the  circulation  is  deficient. 

As  a  rule  the  application  of  local  heat  should  be  supplemented 
by  massage.  The  profuse  general  perspiration  that  is  induced  by  it 
is  a  contra-indication  in  weak  individuals. 


CHAPTER  VI. 
NOX-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

SYPHILITIC  DISEASES  OF  THE  JOINTS. 

In  early  infancy  the  characteristic  manifestations  of  congenital 
s^^hihtic  disease  of  the  bones  is  a  form  of  osteochondritis.  Sensi- 
tive swelhngs  appear  at  the  epiphyseal  junctions,  either  as  small, 
hard  tumors  or  as  general  enlargements,  resembling  those  of  rha- 
chitis  (Fig.  213).  As  a  rule  several  epiphyses  are  involved,  more 
often  those  at  the  distal  extremities  of  the  bones  of  the  lower  limbs, 
and  in  these  cases  the  pain  and  discomfort  may  induce  an  appear- 
ance of  helplessness  of  the  part  called  pseudoparalysis  (Parrot). 


Fig.  213. — Suppurative  syphilitic  epiphysitis  at  lower  ends  of  radius  and  tibia  in 
an  infant  aged  one  month.  The  child  died  shortly  after  the  drawings  were  made 
and  the  epiphyses  were  found  Ij-ing  loose  in  purulent  cavities.     (Tubby.) 

In  sj-philitic  osteochondritis  there  is  a  multiplication  and  irregu- 
larity of  the  cartilage  cells  of  the  ossifWng  laj^er  and  premature 
calcification.  Necrosis  may  result  as  shown  by  a  zone  of  hard,  dry 
yellow  substance  in  the  ossifying  layer  of  the  cartilage,  about 
which  newly  formed  bone  is  softened  and  in  part  replaced  by  granu- 


SYPHILITIC  DISEASES  OF   THE  JOINTS  271 

lation  tissue.  If  the  disease  is  progressive,  ulceration  and  suppura- 
tion may  follow;  the  cartilage  may  be  destroyed,  and  the  epiphysis 
may  be  separated,  causing  deformity  and  cessation  of  growth.  The 
neighboring  joint  is  usually  involved  in  the  disease.  In  the  milder 
cases  there  is  a  simple  sympathetic  synovitis;  in  the  advanced  class 
a  destructive  arthritis.  In  one  case  seen  recently  in  a  child  three 
months  of  age  the  symptoms  of  pain  on  motion  combined  with  slight 
effusion  into  several  joints  were  present  without  the  epiphyseal 
enlargement.  The  affection  may  be  distinguished  from  rhachitis 
by  the  accompanying  evidences  of  inherited  syphilis,  by  the  irregu- 
larity of  the  epiphyseal  enlargements,  and  by  the  age  of  the  patient 
and  the  absence  of  the  other  symptoms  of  rhachitis.  The  a;-ray 
picture  in  characteristic  cases  shows  at  the  diaphyseal  extremities 
of  the  long  bones,  irregular  and  indented,  in  outline  on  the  epi- 
physeal margin.^ 


Fig.  214. — Congenital  syphilis. 

In  the  later  manifestations  of  hereditary  syphilis,  in  which  the  bones 
in  the  neighborhood  of  the  joint  are  involved  in  syphilitic  osteoperi- 
ostitis, the  joint  may  be  sympathetically  affected  or  the  disease  may 
actually  perforate  the  joint.  In  this  form  of  disease  the  synovial 
membrane  is  usually  hypertrophied  to  such  degree  as  to  interfere 
with  movement.  The  fluid  is  increased  in  quantity  and  the  affec- 
tion may  resemble  synovial  tuberculosis.  A  slow,  chronic,  infiltrat- 
ing gummatous  form  of  disease  appearing  in  later  childhood  may 
simulate  very  closely  the  appearance  of  so-called  white  swelling.  It 
is  more  common  at  the  knee,  but  other  joints  are  often  affected 
as  well.  In  other  instances  one  or  more  of  the  joints  may  be 
involved  before  the  enlargement  of  the  neighboring  bone  is  apparent, 
the  symptoms  being  those  of  chronic  synovitis. 

The  diagnosis  of  hereditary  syphilitic  arthritis  is  usually  suggested 
by  the  history  and  is  confirmed  by  the  Wassermann  reaction  and 
other  evidences  of  the  disease.  The  most  important  of  these  is 
keratitis.  In  a  series  of  77  cases  in  which  this  was  present  there 
was  involvement  of  the  joints  in  56  per  cent.,  the  knee  being  most 
often  affected.2  Spina  ventosa  (Fig.  216),  which  is  classed  as  one 
of  the  evidences  of  syphilis,  is  far  more  commonly  of  tuberculous 

1  Frankel:  Archiv  u.  Atlas  d.  norm.  u.  path.  Anatomy,  1911,  xxvi. 

2  Hippel:  Miinchen.  med.  Wchnschr.,  1903,  No.  31. 


272         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

origin,  as  is  illustrated  by  the  statistics  of  Karewski/  of  157  cases, 
in  which  but  3  were  due  to  syphilis.  Acquired  syphilitic  arthritis 
usually  appears  in  the  later  secondary  stages  of  the  disease,  most 
often  as  a  multiple  subacute  involvement  of  the  larger  joints, 
accompanied  by  sensitiveness  of  the  adjoining  bones.  Occasionally 
the  onset  is  acute  and  accompanied  by  fever,  so  that  it  may  be  mis- 
taken for  rheumatism.  In  the  tertiary  stage  the  joints  may  be 
involved,  either  primarily  in  a  gumma  formation,  or  secondarily 
from  disease  in  a  neighboring  bone.  The  symptoms  are  usually 
subacute.  2 


Fig.  215. — Syphilitic  osteoperiostitis  of  the  tibice  resembling  anterior  bow-leg. 
This  is  the  most  characteristic  manifestation  of  hereditary  syphilis.  It  induces  not 
only  deformity  and  hypertrophy,  but  elongation  of  the  affected  bone  as  well. 

Syphilitic  disease  of  the  joints  is  comparatively  rare  in  ortho- 
pedic clinics  as  contrasted  with  those  of  tuberculous  origin.  This 
is  as  might  be  expected,  since  it  is  estimated  that  50  per  cent,  of 
syphilitic  infants  are  born  dead  and  that  only  25  per  cent,  survive 

1  Chir.  Krank.  des  Kindesalters. 

2  Bona:  Berlin    klin.  Wchnschr.,  1907,  Nos.  43  and  44. 


SYPHILITIC  DISEASES  OF   THE  JOINTS 


273 


the  first  year.^  Even  among  these  disease  of  the  bones  or  joints,  in 
the  form  that  could  be  confounded  with  tuberculosis,  is  uncommon 
as  compared  with  its  other  manifestations. 


Fig.  216. — Hereditary     syphilitic     dis- 
ease of  the  metacarpus  and  phalanges 


Fig.  217. — Hereditary  syphilitic  dis- 
ease of  the  joints.  In  this  case  the 
interior  of  the  right  knee-joint  was 
lined  with  hypertrophied  folds  of  syno- 
vial membrane.  A  complete  cure  fol- 
lowed the  administration  of  appropriate 
remedies. 


Disease  of  the  bones  is  more  common  than  of  the  joints  because  as 
contrasted  with  tuberculosis  it  usually  affects  the  diaphyses.  In 
212  cases  of  hereditary  syphilis  over  two  years  of  age  recorded  by 
Fournier  the  bones  were  involved  in  38  per  cent.  It  is  in  further 
contrast  of  the  formative  rather  than  of  the  destructive  type. 


18 


Rostenberg:  Med.  Rec,  .July  1,  1916. 


274         NOX~TUBERCULOUS  DISEASES  OF   THE  JOIXTS 

Treatment. — Certain  writers  consider  hereditary  syphilis  to  be  a 
very  important  predisposing  cause  of  tuberculous  disease,  and 
believe  that  many  cases  classed  as  tuberculous  are  in  reality  s^'phi- 
litic,  even  if  no  history  or  confirmatory  signs  of  syphilis  are  present. 
As  evidence  on  this  point  the  observations  of  Menard  may  be  cited. 
He  found  in  16  of  700  tuberculous  cases  under  treatment  positive 
signs  of  hereditary  syphilis.  The  possibility  of  the  syphilitic  taint, 
remote  or  direct,  should  be  borne  in  mind  even  if  the  ^Yassermann 
test  is  negative  and  in  all  doubtful  cases  appropriate  remedies 
should  be  employed.^ 

In  general  the  treatment  of  the  joint  affection  would  be  included 
in  the  treatment  of  the  disease  of  which  it  is  a  complication.  If  the 
joint  is  involved  in  a  destructive  process,  apparatus  to  ensure  rest 
and  protection  is  indicated.  The  removal  of  irritative  disease  in 
the  neighborhood  of  a  joint  is  sometimes  possible  in  older  subjects, 
and  in  this  class  of  cases  an  exploratory  incision  for  inspection  of 
the  jomt  is  sometimes  advisable  (Fig.  217). 

ARTHRITIS. 

Gonorrheal  Arthritis. — Synonym. — Gonorrheal  rheiunatism. 

So-called  gonorrheal  rheumatism  is  an  inflammation  of  a  joint 
caused  by  the  presence  of  gonococci.  It  complicates  from  2  to  5 
per  cent,  of  all  the  cases  of  gonorrhea,  usually  appearing  several 
weeks  after  infection,  and  it  is  more  common  among  those  who  are 
in  a  debilitated  condition. 

Distribution. — In  about  40  per  cent,  of  the  cases  it  is  monarticular 
and  the  knee-joint  is  most  often  involved.  In  375  cases  collected 
by  Finger  the  distribution  was  as  follows:- 

Knee 136  Shoulder 24 

Ankle 59  Hip 18 

Wrist 43  Jaw 14 

Finger-joints 35  Other  articulations       ...  21 


Elbow 25 


375 


Bennecke^  has  tabulated  78  cases  in  56  patients,  of  whom  IS  were 
males,  .38  females.     The  distribution  was  as  follows: 

Knee      .......  31  Shoulder 4 

Hip 8  Elbow    . 10 

Ankle 9  Wrist 6 

Other  joints  of  foot      ...  6  Fingers 4 

78 

1  Fisher:  Jour.  Am.  Med.  Assn.,  February  3,  1917. 
-  Taylor:  Venereal  Diseases,  263. 

3  Die  Gon.  Gelenkentziindung  nach  beob.,  der  Chir.  univ.  Klin,  in  der  K.  Charite 
zu  Berlin.    Hirschwald,  Beriin,  1899. 


ARTHRITIS  275 

In  46  cases  recorded  by  Markheim^  one  joint  was  involved  in  13 
cases,  two  joints  in  12,  three  joints  or  more  in  18.  The  order  of 
frequency  was  knee,  hip,  shoulder,  wrist,  and  elbow. 

Symptoms.^ — The  affection  is  usually  of  a  subacute  character. 
The  joint  becomes  swollen  and  there  is  discomfort,  and  particularly 
weakness  and  stiffness  on  use.  If  the  infection  is  more  severe  there 
may  be  local  heat,  pain,  and  infiltration  of  the  tissues,  with  accom- 
panying muscular  spasm. 

In  all  th^  forms  the  infiltration  of  the  subsynovial  tissues  of  the 
capsule  and  of  the  superficial  tissues  is  more  marked  than  the  actual 
effusion  within  the  joint  and  it  may  be  inferred  that  in  many  in- 
stances the  bone  is  itself  involved,  although  not  to  the  extent  to  be 
classified  as  osteomyelitis.  The  more  serious  cases  are  characterized 
by  a  pecuHar  edematous  swelling  of  the  deeper  tissues,  the  skin 
being  hot,  sensitive,  and  glazed.  There  is  usually  intense  pain  on 
motion  of  the  limb  or  on  jar.  After  the  subsidence  of  the  acute 
symptoms  the  thickening  persists,  and  practical  anchylosis  may 
result. 

Gonorrheal  arthritis  may  be  divided  into  three  classes,  according 
to  its  symptoms  and  physical  characteristics:  the  serous,  the  sero- 
fibrinous, the  purulent. 

The  serous  form  is,  as  its  name  implies,  a  simple  effusion  resembling 
other  forms  of  subacute  synovitis,  although  it  is  of  a  more  chronic 
character. 

The  serofibrinous  variety  is  the  so-called  plastic  type  of  inflam- 
mation. In  this  form  fibrin  is  deposited  upon  the  cartilage  and  it 
is  afterward  organized  by  the  growth  of  vessels  into  it  from  the 
synovial  membrane,  a  process  which  erodes  the  cartilage  upon  which 
the  granulations  rest.  The  folds  of  the  synovial  membrane  adhere 
to  one  another,  the  capsule  is  thickened,  and  ligaments  and  terdons 
may  be  involved  in  the  adhesive  inflammation.  These  changes 
within  and  without  the  joint  may  seriously  impair  its  function  after 
the  cure  of  the  active  disease. 

The  purulent  form  is  uncommon;  it  is  similar  in  its  characteristics 
to  suppurative  arthritis  from  other  cases.  It  is  attended  by  great 
local  heat,  pain,  and  swelling,  and  by  constitutional  disturbance. 

In  orthopedic  clinics  gonorrheal  arthritis  is  usually  seen  in  its 
later  stages  when  the  acute  symptoms  have  subsided.  In  these 
cases  swelling  and  pain  persist  in  many  instances,  and  in  the  more 
severe  types  motion  is  limited  or  the  limb  may  be  fixed  in  an  atti- 
tude of  deformity.  An  obstinate,  monarticular  painful  swelling  of 
a  joint  suggests  gonorrhea,  and  its  presence  or  absence  should 
always  be  determined,  since  the  effective  treatment  of  the  primary 
cause  is  essential  to  the  cure  of  the  secondary  affection  of  the  joint. 
The  same  statement  is  true  of  painful,  persistent  affections  of  bursffi 

1  Deutsch.  Archiv.  f.  klin.  Med.,  1902,  Ixxii,  186. 


276         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

and  tendon  sheaths,  and  of  obstinate  forms  of  weak  foot  in  which 
sensitive  heels  and  stiffened  toe-joints  are  present. 

Treatment. — The  first  indication  is  efficient  treatment  of  the  ure- 
thral disease  by  such  local  and  systemic  remedies  as  may  be 
indicated.  Fuller,  of  New  York,  has  reported  several  cases  in 
which  cure  of  persistent  disease  of  joints  and  tendon  sheaths  fol- 
lowed direct  treatment  of  gonorrheal  disease  in  or  about  the  seminal 
vesicles.  The  local  treatment  of  the  early  stage  of  this  form  of 
arthritis  is  rest  by  splinting  or  by  traction,  together  with  hot  or 
cold  applications,  as  may  seem  to  be  indicated.  Ichthyol  ointment 
in  a  proportion  of  about  40  per  cent,  appears  to  relieve  the  pain  and 
to  stimulate  the  absorption  of  the  effusion.  If  the  symptoms  are 
acute  and  if  there  is  constitutional  disturbance,  the  joint  should  be 
aspirated,  and  if  the  examination  shows  the  effusion  to  be  sero- 
purulent,  it  should  be  incised,  irrigated  with  hot  salt  solution  and 
closed.  In  the  chronic  form,  also,  when  the  capsule  is  distended 
by  the  serofibrinous  eftusion,  incision  and  removal  of  the  contents 
is  indicated. 

In  the  latter  stages  of  disease  of  the  ordinary  subacute  type  the 
treatment  is  directed  to  the  absorption  of  the  effused  material  within 
and  without  the  joint,  and  to  the  restoration  of  functional  activity. 
The  use  of  hot  air,  massage,  passive  congestion,  the  hot  and  cold 
douche,  static  electricity  and  the  like  are  of  service  in  stimulating 
the  circulation.  If  the  limb  has  become  deformed,  and  if  it  is  fixed 
by  adhesions  and  by  contractions,  the  deformity  may  be  corrected 
by  forcible  manipulation  under  anesthesia.  And  it  may  be  stated 
that  in  this  class  of  cases  restoration  of  function  to  a  greater  or  less 
degree  is  often  accomplished  by  this  means. 

If,  however,  the  limb  is  fixed  in  the  proper  position  it  is  well  to 
postpone  forcible  measures  until  the  effect  of  the  massage  and  gentle 
passive  movements  have  been  observed. 

Functional  use  is  the  most  effective  restorative  treatment  after 
the  acute  symptoms  have  subsided.  This  is  made  possible  by  the 
emplojTuent  of  apparatus  which  limits  motion  to  the  degree  the 
joint  permits  without  causing  discomfort. 

Gonorrheal  Arthritis  in  Infancy. — ^This  complication  in  infancy 
is  usually  a  multiple  arthritis  of  a  pyemic  character.  In  a  series 
of  78  cases  of  gonorrheal  infection  treated  at  the  Babies'  Hospital^ 
there  were  10  cases  of  arthritis,  6  died  directly  from  the  disease,  2 
died  later  from  exliaustion,  and  in  the  2  remaining  recovery  seemed 
improbable. 

Puerperal  Arthritis. — This  is  so  similar  in  its  characteristics  to 
gonorrheal  arthritis  in  adults  that  a  detailed  description  is  unneces- 
sary. It  may  be  stated,  however,  that  puerperal  arthritis  is  usually 
of  a  more  severe  type  than  the^preceding  affection. 

1  Kimball:  Med.  Rec,  November  14,  1903. 


ARTHRITIS  277 

"^ 
Arthritis  Complicating  Infectious  Diseases. — The  joints  may 
be  involved  in  the  course  of  any  infectious  disease.  A  mild  form 
of  arthritis,  often  involving  several  joints,  may  be  a  sequel  of  infec- 
tious disease,  notably  scarlatina.  Brade^  has  reported  60  cases  of 
joint  involvement  in  868  cases  of  scarlatina  treated  in  St.  Jacob's 
Hospital;  56  were  of  the  serous  type;  4  were  of  the  suppurative 
form,  causing  the  death  of  the  patients.  In  but  8  of  the  cases  was 
the  arthritis  limited  to  a  single  joint. 

Arthritis  may  complicate  pneumonia  in  about  1  per  cent,  of  the 
cases  appearing  usually  about  the  eleventh  day;^  or  cerebrospinal 
meningitis,  as  in  10  of  63  cases  reported  by  Sainton  and  Mailee.^ 

Arthritis  following  typhoid  fever  is  often  of  a  severe  and  destructive 
type.  Keen*  has  tabulated  84  cases.  In  43  per  cent,  of  these  the 
hip-joint  was  affected  and  in  40  per  cent,  spontaneous  dislocation 
occurred.  In  a  case  treated  recently  at  the  Hospital  for  Ruptured 
and  Crippled  there  had  been  a  destructive  arthritis  of  one  hip-joint, 
spontaneous  displacement  of  the  femur  on  the  other  side,  and  sec- 
ondary contractions  at  the  knees  and  ankles,  so  that  the  patient 
was  bed-ridden.     (See  Typhoid  Spine.) 

Prognosis. — It  is  evident  that  the  immediate  reaction  to  bacterial 
infection  and  the  final  results  will  vary  with  the  virulence  of  the 
infection,  the  natural  resistance  of  the  individual,  and  of  the  part 
invGlved."^  The  bacteria  reach  the  synovial  membrane  through  the 
capillaries  of  the  areolar  tissue,  beneath  the  endothelium,  which  if 
uninjured  serves  as  a  barrier  to  protect  the  joint  cavity.  If  the 
joint  is  not  actually  involved  the  restriction  to  motion  will  depend 
upon  thickening  of  the  tissues  of  the  joint  and  upon  disuse  of  the 
muscles.  In  such  cases  the  prognosis  is  good.  If,  however,  the 
interior  of  the  joint  is  invaded  by  a  process  that  causes  adhesions,  and 
partial  destruction  of  the  cartilaginous  surfaces,  anchylosis  is  likely 
to  follow. 

Treatment. — The  treatment  of  all  forms  of  arthritis  compHcating 
diseases  of  this  class  is  to  place  the  affected  joint  at  rest,  to  apply 
heat  or  cold  as  may  be  indicated  by  the  local  condition,  and  to  pre- 
vent the  secondary  distortions  that  lead  to  fixed  deformities.  The 
presence  of  pus  is,  of  course,  an  indication  for  immediate  incision, 
thus,  in  all  doubtful  cases  the  character  of  the  effusion  should  be 
ascertained  by  aspiration.  The  injection  of  about  6  c.c.  of  5  per  cent, 
solution  of  tincture  of  iodin  in  alcohol  is  recommended  by  Dreyer.^ 
Spontaneous  dislocation,  which  is  comparatively  common  when 
the  hip-joint  is  suddenly  distended  with  fluid,  is  not  likely  to  occur 


1  Leipzig,  1903. 

2  Howard:  Johns  Hopkins  Hosp.  Bull.,  1910. 

3  Bull,  de  I'Acad.  de  Med.,  Ixxiii,  No.  14. 

*  Surg.  Complications  and  Sequels  to  Typhoid  Fever. 

5  Poynton  and  Paine:  British  Med.  Jour.,  November  1,   1902. 

6  Beitr.  z.  klin.  Chir.,  August  11,  1911. 


278         NOX-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

unless  the  limb  is  flexed  and  adducted.  This  attitude  should  be 
prevented  by  the  use  of  traction  or  support. 

The  after-treatment  has  been  indicated  already. 

Acute  Arthritis  of  Infancy. — A  form  of  acute  suppurative  arthritis 
primarily  within  the  joint  or  more  often  secondary  to  disease  of  the 
neighboring  epiphysis  is  not  uncommon  in  infancy. 

Etiology. — The  disease  is  usually  caused  by  staphylococci,  occa- 
sionally by  other  forms  of  infection.  (See  Gonorrheal  Arthritis.) 
In  the  earl\'  weeks  of  life  it  may  follow  infection  at  the  umbilicus 
or  other  surface  lesion.  It  may  be  secondary  to  one  of  the  exanthe- 
mata or  to  gonorrhea,  but  in  many  instances  the  origin  is  not 
apparent. 

Falls  or  blows  upon  the  part  appear  to  be  predisposing  causes. 

Townsend^  tabulated  73  cases  of  acute  arthritis,  IS  of  which  were 
personal  observations.  To  these  I  am  able  to  add  12  others,  making 
a  total  of  So  cases.  In  64  of  these  the  infection  was  monarticular; 
in  21  more  than  one  joint  was  involved.  The  distribution  was  as 
follows : 

Hip-joint 45   =  53  per  cent. 

Knee-joint     .       .  32   =  .37  " 

Other  joints 8   =  10  " 

Sex. — The  sex  was  specified  in  61  cases:  males,  3S;  females,  23. 
It  is  of  interest  to  note  that  in  all  reported  cases  the  males  outnumber 
the  females.  In  2S5  cases,  including  the  above  and  others  reported 
by  Gonser,  Demme,  Liicke,  Billroth,  Schede,  and  Miiller,  the  pro- 
portion was  nearly  3  to  1.- 

Symptoms. — If  the  infection  is  severe  there  is  immediate  local  heat, 
redness,  swelling  and  edema,  great  pain,  and  corresponding  consti- 
tutional disturbance.  But  in  many  instances  the  local  and  general 
s^Tnptoms  are  less  marked,  the  child  is  fretful,  and  the  evident  dis- 
comfort caused  by  motion  at  the  affected  joint  is  mistaken  for  the 
result  of  injury  or  rheumatism.  In  this  class  of  cases  the  patient  is 
not,  as  a  rule,  seen  until  several  weeks  after  the  onset  of  the  affection. 
The  joint  is  then  somewhat  infiltrated  and  enlarged,  motion  is  pain- 
ful and  restricted,  and  the  general  appearances  are  very  similar  to 
tuberculous  disease.  There  are  also,  without  doubt,  even  milder 
forms  of  s^^lovial  infection  from  which  recovery  is  rapid  and  prac- 
tically complete.  These  cases  are  usually  classed  as  monarticular 
rheumatism.  Similar  symptoms  may  be  induced  directly  by  injury; 
motion  causes  pain;  the  limb  is  flexed  and  persistent  deformity  may 
result  unless  protection  is  assiued. 

Prognosis. — If  the  disease  is  confined  to  the  joint  complete  recovery 
may  follow  evacuation  of  the  pus,  but,  as  a  rule,  the  neighboring 
epiphyseal  junction  is  diseased,  suppuration  is  prolonged,  and  a  part 

1  Am.  Jour.  Med.  Sci.,  January,   1890. 
-  Gonser:  Jahrb.  f.  Kinderh.,  July,  1902. 


ACVTE  OSTEOMYELITIS  '27^ 

of  the  epiphysis  is  destroyed  before  the  disease  comes  to  an  end; 
thus,  subluxation  or  displacement  with  subsequent  deformity  and 
loss  of  growth  are  the  usual  results  of  this  form  of  disease.  At  the 
hip-joint,  for  example,  the  laxity  of  the  ligaments  and  the  upward 
displacement  of  the  femur  that  follow  destruction  of  the  head  of  the 
bone  cause  symptoms  that  in  later  life  are  often  mistaken  for  those 
of  congenital  dislocation. 

In  some  of  the  cases  there  is,  in  addition  to  the  arthritis,  an 
osteomyelifis  of  the  shafts  of  one  or  more  of  the  bones.  These  cases 
are  usually  fatal,  or,  if  the  patient  survives,  there  is  usually  necrosis 
of  the  affected  bones  and  consequently  extreme  deformity. 

In  the  cases  reported  by  Townsend  the  death-rate  was,  in 
monarticular  form,  18  per  cent. ;  in  the  multiple  form,  73  per  cent. 

In  a  total  of  122  cases  of  all  varieties  tabulated  by  Hoffmann,  the 
death-rate  was  46  per  cent.  In  87  the  affection  was  confined  to  one 
joint;  in  the  remainder  from  two  to  five  joints  were  involved.^ 

Treatment. — The  treatment  of  suppurative  arthritis  is  free  incision 
and  efficient  drainage.  In  all  cases  the  joint  must  be,  fixed,  prefer- 
ably by  a  light  wire  splint,  during  the  active  stage  of  the  disease. 
An  apparatus  is  usually  required  to  prevent  deformity  or  to  support 
the  weak  limb  when  the  patient  begins  to  walk. 

Acute  Tuberculous  Arthritis. — In  early  infancy  forms  of  acute 
tuberculous  disease,  especially  at  the  knee-joint,  may  simulate 
closely  infectious  arthritis.  The  joint  may  become  swollen,  hot, 
and  sensitive  to  pressure,  and  the  onset  may  be  sudden  and  accom- 
panied by  constitutional  disturbance.  Such  cases  are  more  often 
observed  in  the  children  of  mothers  suffering  from  advanced  disease 
of  the  lungs. 

ACUTE  OSTEOMYELITIS. 

The  bone  marrow  belongs  to  the  lymphatic  system  and  all  the 
changes  characteristic  of  osteomyeltis  are  secondarj^  to  the  primary 
disease  of  this  tissue.  Osteomyelitis  is  essentially  a  disease  of  child- 
hood and  adolescence.  The  extremities  of  the  bones  in  the  neighbor- 
hood of  the  epiphyseal  cartilages  on  the  diaphyseal  side  are  most 
often  involved.  Trendel,  from  the  histories  of  1058  cases  treated  in 
Bruns's^  clinic,  states  that  it  is  most  common  in  the  period  from  the 
thirteenth  to  the  seventeenth  year.  In  one-half  of  the  cases  the 
femur  was  involved;  in  one-third  the  tibia.  In  some  instances  the 
source  of  the  infection  seems  apparent  in  tonsillitis,  furuncles,  local 
infections  and  the  like.  In  others  no  such  cause  can  be  assigned. 
In  possibly  25  per  cent,  of  the  cases  injury  has  apparently  deter- 
mined the  site  of  the  disease.^ 

1  Med.  Bull.,  Washington  University,  September,   1902. 

-  Beitr.  z.  klin.   Chir.,  xli,  3. 

^  Homans:  Ann.  Surg.,  March,  1912. 


280         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

The  s^^nptoms  are  usually  chill,  fever,  local  pain  and  sensitiveness 
to  pressm-e  in  the  neighborhood  of  a  joint  which  is  soon  distended 
by  a  sympathetic  synovitis,  and  the  overlying  tissues  are  usually 
infiltrated.  The  treatment  consists  in  immediate  free  opening 
of  the  bone  at  the  suspicious  point,  in  order  to  relieve  the 
tension  and  to  establish  drainage.  In  certain  instances  the 
joint  itself  may  be  directly  involved  in   the   disease.     This   may 


Fig.   218. — Deformities  resulting  from  infectious  osteomyelitis. 

be  inferred  if  the  symptoms  do  not  subside  after  the  bone  has  been 
opened.  In  doubtful  cases  the  joint  should  be  aspirated  for  the 
purpose  of  bacteriological  examination,  but  even  if  pathogenic 
bacteria  are  present  the  treatment  by  incision  or  otherwise  must  be 
decided  on  the  clinical  symptoms;  for  the  investigations  of  Fraenkel 

1  Mit.  a.  d.  grenzgebieten  d.  Med.  u.  Chir.,  xii. 


ACUTE  OSTEOMYELITIS 


281 


Fig.  219. — Tuberculous  osteomyelitis  localized  in  the  lower  extremities  of  the 
radius  and  ulna,  demonstrated  by  the  x-rays  and  removed  before  the  wrist-joint  was 
involved. 


Fig.  220. — Loss  of  growth  following  osteomyelitis  of  the  tibia,  necessitating  removal 

of  part  of  the  shaft. 


282 


NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 


show  that  specific  microorganisms  are  present  in  the  red  marrow  of 
the  vertebra?,  in  the  ribs  and  elsewhere  in  every  form  of  mfectious 
disease,  and  that  they  may  be  found  here  even  when  they  are  absent 
in  the  blood.  In  the  blood,  according  to  Bertelsmann,^  they  may 
be  found  in  about  one-third  of  all  cases  of  sm-gical  infection  and  far 
more  often  when  bones  or  joints  are  involved.  In  a  series  of  48 
positive  results  streptococci  were  fomid  in  68  per  cent.,  staphylococci 
in  30  per  cent. 


Fig.   221. — Cyst  and  fracture. 


The  prognosis  in  neglected  cases  is  bad :  for  example,  in  54  cases 
of  acute  osteomyelitis  of  the  upper  extremity  of  the  femur,  in  all  but 
7  of  which  the  joint  was  involved,  the  death-rate  was  60  per  cent.- 

Localized  chronic  osteomyelitis  in  the  neighborhood  of  a  joint  may 
simulate  tuberculous  disease  of  the  joint.  The  onset  of  the  affec- 
tion is,  however,  more  abrupt,  the  surrounding  tissues  are  infitrated, 
and  the  symptoms  are  usually  more  acute  than  in  the  latter  affec- 
tion. In  this  class  of  cases  of  the  subacute  t^'pe  the  lesions  are 
often  multiple,  fresh  foci  appearing  at  intervals  for  an  indefinite 
time.  The  treatment  of  choice  when  the  affection  is  localized  is  the 
operative  removal  of  the  diseased  area,  which  is  indicated  by  local 

1  Deutsch.  Ztsciir.  f.  Chir.,  Ixxii,  209. 

2  Gyot:  Rev.  des  Chir.,  xxiv,  Nos.  2  and  4. 


ARTHRITIS  DEFORMANS  283 

sensitiveness,  and  which  in  many  instances  may  be  demonstrated 
by  the  ar-rays.  One  should  be  as  sparing  of  the  bone  as  possible 
because  of  the  danger  of  retardation  or  irregularity  of  growth  that 
almost  always  follows  the  loss  of  even  a  moderate  amount  of  growing 
tissue.^ 

ARTHRITIS  DEFORMANS.     OSTEO-ARTHRITIS  AND  RHEUMA- 
TOID ARTHRITIS.     RHEUMATIC  GOUT.     DEGENERATIVE 
AND  PROLIFERATIVE  ARTHRITIS. 

Under  these  titles  are  included  a  large  group  of  chronic  diseases  of 
the  joints  whose  etiology  is  obscure.  At  the  present  time  as  these 
diseases  are  often  improperly  classed  as  varying  manifestations  of  one 
pathological  process,  the  titles  are  often  considered  as  synonymous. 

Clinically,  however,  the  characteristic  types  differ  markedly  from 
one  another.  In  one  form  bone  destruction  is  combined  with  bone 
formation,  and  the  final  result  is  an  irregular  solid  enlargement  of 
the  joint,  usually  combined  with  distortion  of  the  limb. 

The  term  hypertrophic  or  degenerative  arthritis  may  be  apphed 
to  this  type. 

The  second  form  resembles  chronic  rheumatism  in  its  course  and 
distribution.  The  joints  are  enlarged  but  the  disease  is  essentially 
of  the  soft  parts,  the  articulating  surfaces  are  only  secondarily  and 
superficially  involved.  There  is  no  new  formation  of  bone  or  car- 
tilage but  eventually  a  local  atrophy  of  the  joint  and  of  the  tissues  of 
the  limb  corresponding  to  the  loss  of  function. 

The  final  result  is  deformity  and  limited  motion  or  anchylosis 
without  bony  enlargement  of  the  joint.  This  form  has  been  classed 
from  the  clinical  stand-point  as  atrophic  to  distinguish  it  from  the 
former  or  hypertrophic  form  of  arthritis  deformans  when  the  term 
was  used  to  include  both  varieties. 

Degenerative  (Hypertrophic)  Arthritis. — Pathology. — This  is  one 
of  the  most  ancient  of  diseases,  of  which  evidence  is  found  in  prehis- 
toric remains  not  only  of  man  but  of  animals.  The  characteristic 
type  is  that  seen  in  elderly  subjects,  sometimes  limited  to  a  single 
joint — malum  coxse  senile,  for  example.  The  primary  effects  of  the 
disease  are  most  noticeable  in  the  cartilage,  which  becomes  necrosed 
or  fibrillated  and  finally  worn  away  in  the  parts  subjected  to  greatest 
pressure,  while  it  is  thickened  and  heaped  up  into  irregular  layers  at 
the  periphery,  as  if  under  the  influence  of  pressure  it  had  been 
squeezed  out  from  the  interior  of  the  joint  (Fig.  224).  When  the 
cartilage  disappears,  the  bone,  deprived  of  its  natural  protection, 
is  worn  away,  and  under  the  influence  of  pressure  and  friction  it 
becomes  increased  in  density  and  hardness — "eburnated."  Mean- 
while the  irregular  projections  of  cartilage  at  the  periphery  become 

1  Klemm:  Berlin,  1914. 


28i 


NOX-TUBERCULOUS  DISEASES  OF   THE  JOINTS 


in  part  ossified,  and  this,  together  ^vith  a  formative  periostitis  of  the 
adjoining  bone,  causes  the  irregular  bony  enlargement  combined 
with  destruction  of  the  bearing  surfaces  of  the  bones  characteristic 
of  the  disease.  The  contour  of  the  bones  and  their  mutual  relation 
to  one  another  in  the  joint  are  changed.  The  synovial  Jmembrane 
becomes  hypertrophied  and  its  villi,  some  of  which  may  contain 
cartilagmous    nodules,   project   into  the   joint  in  shaggy    fringes. 


Fig.  222. — Degenerative  arthritis.  The  hypertrophj-  of  the  extremities  of  the 
bones  of  the  terminal  phalanges  (Heberden's  nodes)  is  accompanied  by  erosion  of  the 
cartilage.  The  second  interphalangeal  joint  of  the  second  finger  shows  hj-pertrophy, 
combined  with  destruction  and  lateral  displacement.     (See  Fig.  223.) 


These  may  be  detached  from  tune  to  time  and  may  form  loose 
bodies  within  the  capsule.  The  synovial  fluid  may  be  greatly 
increased  in  quantity  distendhig  the  capsule,  or,  commmiicating 
with  bm-s8e,  it  may  form  cysts,  as  is  sometimes  observed  at  the  knee- 
joint.  But  more  commonly  the  fluid  is  decreased  in  amount.  The 
ligaments  are  weakened  and  the  tendons  about  the  joint  become 
adlierent  to  their  sheaths  and  to  the  neighboring  tissues.     The 


ARTHRITIS  DEFORMANS  285 

muscles  atrophy  and  become  structurally  shortened  or  otherwise 
changed  in  accommodation  to  the  deformity.  Motion  is  limited 
by  the  changes  in  and  about  the  joint  but  anchylosis  is  unusual. 

Although  the  most  noticeable  of  the  early  changes  appear  in  the 
cartilage  it  is  probable  that  the  nutrition  of  the  underlying  bone  is 
lowered  in  the  beginning  and  that  the  joint  is  involved  as  a  whole 
rather  than  that  the  disease  is  primarily  of  the  cartilage. 


Fig.  223. — Atrophic  arthritis.     Slight  superficial  erosions  of  the  bones  are  to  be  seen 
at  several  of  the  joints.    Contrast  with  Fig.  222. 

Etiology. — Little  that  is  positive  is  known  of  the  etiology.  Several 
factors  are  sufficiently  evident.  These  are  age,  injury  or  overstrain, 
overweight  and  improper  functional  use.  The  wearing  out  of  the 
joint  is  suggested  by  the  appearances,  and,  as  is  well  known,  similar 
changes  in  slight  degree  are  not  uncommonly  found  in  the  joints  of 
laborers  of  middle  age.  According  to  Beitzke's  investigations  of 
the  bodies  of  200  laborers,  the  joints  of  those  between  20  and  40 


286         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

showed  changes  characteristic  of  Hmited  degenerative  arthritis  in  5 
per  cent.,  over  40,  60  per  cent.,  over  50,  100  per  cent.^  So,  also, 
similar  changes  may  follow  abnormal  function,  as  in  hallux 
valgus,  or  may  be  induced  by  injury,  particularly  fracture  at 
the  hip-joint.  In  elderly  and  overweighted  subjects  the  symp- 
toms may  be  induced  by  slight  disturbance  of  the  normal 
relation  of  the  bones;  in  the  knee,  for  example,  as  a  sequel 
of  weak  foot.  Lessened  local  and  general  resistance  are  also 
predisposing  causes.  In  locomotor  ataxia,  a  disease  accom- 
panied by  loss  of  sensation  and  by  diminished  control  of  movement. 


Fig.  224. — Hypertrophic  arthritis,  from  the  Museum  of  the  College  of  Physicians 
and  Surgeons,  New  York. 


the  nutrition  of  the  joint  is  lowered  and  its  natural  safeguards 
against  injury  and  overwork  are  removed.  Joint  disease  (Charcot's 
disease)  in  such  instances  is  undoubtedly  an  indirect  effect  of  dis- 
ease of  the  nervous  apparatus,  but  it  by  no  means  follows  that  such 
or  any  disease  of  the  nervous  system  is  necessary  to  explain  the 
lesions  of  the  ordinary  form  of  arthritis  deformans.  It  would 
appear  finally  that  defective  assimilation  (metabolism)  is  a  pre- 
disposing factor  in  both  man  and  animals. 

1  Ztschr.  f.  klin.  Med.,  xxiv,  No.  3. 


ARTHRITIS  DEFORMANS  287 

Symptoms. — In  its  typical  form  hypertrophic  arthritis  is  an  affec- 
tion of  middle  life  and  of  old  age.  It  may  be  confined  to  a  single 
joint,  and  in  these  cases  one  of  the  larger  joints  of  the  lower  extrem- 
ity is  more  often  affected,  particularly  the  hip  or  knee.  As  a  rule, 
however,  several  joints  are  involved  to  a  greater  or  less  degree.  Its 
onset  is  usually  insidious,  and  the  progress  is  slow,  accompanied  by 
remission  of  the  symptoms. 

These  synjptoms  are  usually  pain,  discomfort  in  changing  from 
one  position  to  another,  "creaking"  sensations  in  the  affected  joints, 
gradually  increasing  local  enlargement  and  sensitiveness,  limitation 
of  motion,  and  distortion  of  the  limb.  Typical  examples  are  found 
in  the  hip- joint  (malum  coxse  senile)  and  knee,  and  these  are  de- 
scribed elsewhere. 

Although  the  disease  may  be  confined  to  one  or  more  of  the  larger 
articulations,  it  is  often  accompanied  by  enlargement  of  the  joints 
of  the  fingers.  It  should  be  stated,  also,  that  there  is  a  form  of 
hypertrophic  arthritis  of  comparatively  slight  importance  in  which 
the  disease  is  confined  to  the  joints  of  the  fingers.  It  is  more  com- 
mon in  women  than  in  men,  often  appearing  at  the  time  of  the  meno- 
pause. The  bases  of  one  or  all  of  the  distal  phalanges  become 
enlarged  (Heberden's  nodosities),  and  the  fingers  become  somewhat 
stiff  and  painful,  the  pathology  being  very  similar  to  that  already 
described.  Gradually  other  phalangeal  joints  are  involved  until 
the  fingers  become  deformed  and  function  is  somewhat  inter- 
fered with.  The  disease  is  slowly  progressive,  pain  lessening  as  the 
enlargement  and  stiffness  become  more  apparent.  When  the  dis- 
ease begins  in  this  manner  the  larger  joints  are  not  often  implicated. 
(Fig.  222). 

Treatment. — In  general  this  should  be  directed  to  the  improve- 
ment, if  possible,  of  the  condition  of  the  patient,  particularly  to  the 
condition  of  the  gastro-intestinal  tract  which  often  influences  the 
symptoms  to  a  marked  degree.  The  daily  routine  should  conform 
to  what  the  personal  experience  of  the  patient  shows  to  be  that  best 
adapted  to  the  disability.  The  local  nutrition  may  be  maintained 
by  massage,  electricity,  and  the  like.  Deformity  may  be  prevented 
and  pain  may  be  relieved  by  regulating  the  strain  to  which  the  weak 
part  is  subjected,  if  practicable  by  the  use  of  apparatus.  In  certain 
instances  operative  removal  of.  villous  proliferations  of  the  synovial 
membrane  or  of  solid  projections  that  interfere  with  movement  may 
be  of  service.  (See  Spondylitis  Deformans  and  Osteo-arthritis  of 
the  Hip  and  Knee.) 

Proliferating  (Atrophic)  Arthritis. — This  form  of  chronic  multiple 
arthritis  differs  from  the  preceding  type  in  that  it  is  rather  an  affec- 
tion of  childhood  and  of  early  adult  life  than  of  old  age.  It  is  more 
common  in  females  than  males.  It  is  more  acute  in  its  onset, 
more  rapidly  progressive,  and  more  general  in  its  distribution. 

In  hypertrophic  arthritis  the  cartilage  is  worn  away  at  the  centre 


288         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

of  the  joint,  heaped  up  at  the  periphery  and  the  underlying  bone  is 
involved.  In  typical  atrophic  arthritis  the  affection  is  primarily 
of  the  fibrous  coverings  and  of  the  membranes  of  the  joint,  and  the 
cartilage  is  destroyed  in  the  later  stages  by  a  pannus-like  growth 
from  the  periphery.  There  is  secondary  erosion  of  the  cartilage  and 
of  the  underlying  bone  unaccompanied  by  the  hypertrophy  char- 
acteristic of  the  preceding  disease.  A  spindle-shaped  enlargement 
of  the  finger-joints  is  characteristic,  due  to  the  thickening  of  the  soft 
parts,  but  the  .T-ray  picture  will  not  show  irregular  bone  formation 
but  a  normal  contour  or  at  most  superficial  erosions  of  the  bones 
entering  into  the  formation  of  the  joint.  The  second  interphalan- 
geal  joints  are  usually  involved  primarily.     There  is  usually  flexion 


Fig.  225. — Atrophic    arthritis    in  a    child,    showing    the  characteristic  deformity. 
Nearly  every  joint  in  the  body  was  involved. 


contraction,  and  in  many  instances  general  deviation  of  the  fingers 
toward  the  ulnar  side.  In  younger  subjects,  particularly  in  the 
class  of  cases  in  which  the  onset  of  the  disease  is  acute,  and  in  which 
there  is  considerable  effusion,  there  may  be  subluxation  or  actual 
luxation  of  the  phalanges,  more  often  at  the  metacarpal  articulations, 
combined  with  more  or  less  absorption  of  the  extremities  of  the 
bones.     In  such  instances  motion  is  preserved  in  the  affected  joints. 

In  typical  cases  the  final  result  in  any  joint  is  either  anchylosis 
or  limited  motion  accompanied  by  flexion  deformity.  There  is, 
of  coiuse,  general  atrophy  of  the  muscles  and  of  the  bones  corre- 
sponding in  degree  to  the  functional  disability  that  is  present. 

The  onset  of  atrophic  arthritis  may  be  acute,  resembling  rheu- 
matism, many  joints  being  involved  simultaneously.     It  is  often 


ARTHRITIS  DEFORMANS 


289 


subacute  and  even  limited  primarily  to  a  single  joint,  slowly  extend- 
ing its  area. 

The  larger  joints  may  be  involved  before  those  of  the  hands, 
where  in  contrast  to  the  degenerative  form  the  interphalangeal 


Fig.  226. — Still's  form  of  polyarthritis,  showing  the  general  atrophy,  the  enlarged 
joints,  and  the  prominence  of  the  abdomen,  due  to  amyloid  degeneration  of  the  liver 
and  spleen. 

joints  are  primarily  affected,  or  vice  versa.  In  childhood  the  dis- 
ease often  begins  in  one  of  the  larger  joints,  causing  stiffness,  deform- 
ity, and  pain  on  motion.  There  is  usually  some  local  heat  and  infil- 
tration of  the  tissues  about  the  joint,  increasing  and  diminishing 


Fig.  227. — The  hands  of  the  patient  in  Fig.  226,  showing  a  skin  lesion. 


according  to  the  character  of  the  disease  and  to  the  strain  or  injury 
to  which  the  joint  may  be  subjected.  In  cases  of  this  character 
the  affection  is  usually  mistaken  for  tuberculous  disease  until  the 
involvement  of  other  joints  indicates  the  true  character  of  the 
19 


290         XOX-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

affection.  As  a  rule  the  affection  is  progressive  in  character,  both 
locally  and  generally.  The  range  of  motion  in  the  affected  joint 
becomes  more  and  more  restricted,  the  limb  becomes  flexed,  and, 
finally,  there  is  practical  anchylosis,  usually  due  to  adhesions  and 
contractions  within  and  without  the  joint.  In  those  cases  in  which 
the  cartilage  is  in  part  destroyed  by  the  growth  of  granulation  tissue 
from  the  periphery  there  may  be  actual  bony  union.  In  many 
instances  the  spine  becomes  rigid,  including  the  occipito-axoid  artic- 
ulations, and  practically  every  joint  of  the  body  may  be  finally 
involved,  so  that  the  patient  is  bed-ridden  and  helpless. 

The  disease  is  more  serious  and  more  rapidly  progressive  in  the 
young  than  in  older  subjects.  There  are  periods  of  remission  and 
of  exacerbation.  In  some  instances  the  disease  appears  to  come 
definitely  to  an  end,  leaving  the  stiffened  joints,  and  occasionally 
complete  recovery  takes  place,  but  this  is  unusual. 

A  peculiar  form  of  the  affection,  first  described  by  Still,^  occurs 
in  childhood.  This  begins  usually  in  one  or  more  of  the  larger 
joints.  As  a  rule  it  progresses  rapidly,  and  it  is  accompanied  by 
enlargement  of  the  IjTuphatic  glands,  particularly  those  of  the 
inguinal  region  and  axilla,  and  of  the  liver  and  spleen.  There  is, 
as  a  rule,  moderate  effusion  into  the  joints  and  thickening  of  the 
overlying  tissues.  As  the  muscular  atrophy  is  extreme,  the  joints 
appear  by  contrast  very  much  enlarged.  The  final  outcome  of  the 
disease  if  the  patient  survives  is  anchylosis  and  deformity,  as  in  the 
ordinary  form.     Occasionally  complete  recovery  occurs. 

Etiology. — This  form  of  chronic  arthritis  is  now  generally  classed 
with  the  infectious  diseases  of  joints,  not  caused  by  a  specific  germ 
but  by  streptococci,  staphylococci,  or  other  germs  or  their  muta- 
tions, so  attenuated  that  they  do  not  induce  suppiu*ation.^ 

Contributing  causes  are  apparently  an  inherited  lack  of  vital 
resistance  or  acquired,  it  may  be,  by  overwork  or  strain,  mental 
or  physical. 

Treatment. — This  must  be  directed  primarily  to  the  discovery  and 
removal  of  the  primary  foci  of  infection,  whether  of  the  teeth,  the 
tonsils,  the  genito-urinary  organs,  or  elsewhere.  Especial  attention 
should  be  paid  to  intestional  stasis  and  putrefaction,  as  a  cause  or 
aggravating  factor  of  the  disease.  Free  catharsis  should  be  estab- 
lished and  diet  should  be  easily  assimilated  and  nourishing.  Expo- 
sure to  cold  and  wet,  and  overexertion  or  strain  on  the  painful  joints 
must  be  avoided.  The  use  of  static  electricity,  the  hot-air  and  the 
electric-light  baths,  are  of  service.^  If  the  joints  are  sensitive 
motion  should  be  restricted  to  the  painless  area.  Passive  motion 
or  massage  that  increases  the  pain  or  discomfort  is  harmful,  but 
motion  shoi.ild  be  encouraged  when  the  disease  is  quiescent.     Con- 

1  Medico-Chir.  Tr.,  1897. 

2  Rosenau:  Jour.,  Lancet,  January  1,  1914. 
^  Nathan:  Am.  Jour.  Aled.  Sc,  June,  1909. 


ARTHRITIS  DEFORMANS 


291 


traction  deformity  may  be  overcome  by  forcible  manipulation,  and, 
if  necessary,  by  tenotomy  when  the  disease  is  quiescent.  And  it  has 
even  been  suggested  that  forcible  manipulation  under  ether  may 
have  a  general  as  well  as  local  remedial  effect.  Excision  of  an 
anchylosed  joint,  as  of  the  lower  jaw  or  elbow,  may  reestablish 
painless  motion.^  Drugs  have  little  influence  on  the  disease.  The 
most  effective  internal  remedies  are  the  thyroid  and  pituitary  glands, 
which  act  by  apparently  stimulating  metabolism.  Autogenous 
vaccines  are  sometimes  of  apparent  benefit. 

The  treatment  of  infectious  arthritis  has  been  discussed.     It  may 
be  that  a  primary  infection  of  a  single  joint  or  of  other  tissues  or 


Fig.  228. — Proliferating  arthritis  in  a  child  affectiuy:  the  joints  and  the  spine 
progressive  in  character,  accompanied  by  enlargement  of  the  lymphatic  glands. 
The  attitude  of  the  head  is  characteristic  of  suboccipital  disease.  The  case  is  one  of 
the  Still  type. 

organs  may  be  the  starting-point  of  multiple  arthritis.  In  such  cases 
operation  with  the  aim  of  removing  the  focus  of  infection  may  be 
considered. 

It  may  be  noted  as  of  interest  that  what  appears  to  be  typical 
atrophic  arthritis  in  childhood  may  be  induced  apparently  by  infec- 
tious disease,  such  as  diphtheria  for  example,  and  that  improvement, 
or  even  disappearance,  of  the  local  symptoms  may  follow  intercur- 
rent attacks  of  scarlatina  or  measles. 

Although,  as  has  been  indicated,  proliferative  and  degenerative 
arthritis  differ  so  essentially  as  to  be  classed  as  distinct  diseases, 


1  Whitman:  Med.  Rec,  April  18,  1903. 


292 


XOX-TUBERCULOUS  DISEASES  OF   THE  JOIXTS 


yet  there  are  t^'pes  that  it  is  difficult  to  classify  as  the  one  or  the 
other,  and  in  certain  instances  the  two  forms  may  be  combined  in 

one  individual.^ 


Gout. 


Gout. — Gout  is  comparatively  of  slight   importance   from  the 
orthopedic  stand-point.    It  affects  more  particularly  those  of  middle 


Fig.  230. — Degenerative  arthritis ;  moderate  degree.  Photomicrograph  of  section 
through  a  phalangeal  joint  and  adjacent  phalanges  shows  that  the  line  of  the  joint 
ca^■ity  is  very  irregular.  Areas  of  hj-perplasia  of  the  cartilage  (1),  with,  in  other 
places,  erosion  of  the  cartilage  down  to  eburnated  bone  of  the  opposing  phalanx  (2). 
In  other  cases  the  cartilage  shows  fibrillation  (3).  There  is  moderate  thickening 
of  the  capsule.     (Nichols  and  Richardson. )- 

life  and  it  is  characterized  by  acute  inflammatory  attacks  followed 
by  deposits  of  urate  of  sodium  on  or  about  the  articular  siu-faces  of 


1  G.  R.  Elliott:  Med.  Rec,  September  23  and  October  14,  1916. 
-  Arthritis  Deformans,  Boston,  1910. 


GOUT 


293 


the  affected  joints.  After  repeated  attacks  the  cartilage  and  the 
bone  may  be  in  part  destroyed,  and  the  joint  may  be  enlarged  by 
deposits  in  the  periarticular  tissues  and  by  the  linflammatory  thick- 


-f^^ 

p^ 

\\  -f^^t 

w  ' 

^ 

^ip^li 

ntf^^uF^ 

l-»      2 

£0 

i^gifwT 

^t^tl^m 

mt 

|n^ 

P 

Fig.  231. — Degenerative  arthritis;  moderate  degree.  Photomicrograph  of  the 
phalangeal  joint  and  adjacent  phalanges.  The  line  of  the  joint  cavity  is  very  irregular 
{1) ;  the  cartilage  has  been  almost  entirely  destroyed  and  shows  only  at  the  margins 
of  the  joint  {2,  2) ;  the  articular  surface  of  the  phalanges  where  the  cartilage  has 
been  destroyed  is  eburnated  (5,  3) .  There  has  been  a  new  growth  of  bone  at  the 
periphery  of  the  joint  (beginning  Heberden's  node)  {Ji).     (Nichols  and  Richardson.) 

ening  of  the  neighboring  joints.  The  joints  most  often  involved 
are  that  of  the  great  toe,  the  ankle,  knee,  and  the  joints  of  the  fingers. 
If  the  feet  are  weakened  or  distot'ted  as  the  effect  of  gout,  a  proper 
support  to  distribute  the  weight  more  generally  on  the  sole  is  often 


Fig.  232. — Proliferative  arthritis;  extreme  type.  Photomicrograph  of  section 
through  phalangeal  joint.  The  trabeculse  of  the  phalanges  are  less  numerous  than 
normal;  the  capsule  is  slightly  thickened;  the  joint  cavity  is  much  reduced  in  size 
by  extension  inward  of  dense,  fibrous  tissue  from  the  synovial  membrane  at  the 
point  indicated  by  the  circle:  this  fibrous  pannus  is  adherent  to  both  joint  cartilages, 
producing  adhesion  and  loss  of  motion  without  destruction  of  the  underlying  car- 
tilage.    (Nichols  and  Richardson.) 


of  service.  The  operative  removal  of  unsightly  deposits  about 
joints  may  be  considered  also.  The  general  treatment  of  the  patient 
is,  of  course,  of  first  importance. 


294 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS 


Rheumatism. — Certain  forms  of  rheumatism,  so-called,  are  of 
interest  from  the  orthopedic  stand-point,  notably  those  forms  that 
affect  the  fibrous  tissues  and  that  lead  to  permanent  changes  in 
the  joints — "plastic  rheumatism."  Undoubtedly  monarticular 
arthritis  is  usually  due  to  dhect  infection  from  without,    as    are 


Fig.  233. — Proliferative  arthritis;  extreme  type.  Vertical  section  through  phalan- 
geal joint.  Shows  the  distal  phalanx  (1) ;  dislocated  forward  and  downward  into  the 
palm  of  the  hand;  the  joint  cavity  (2)  is  practically  obliterated  and  replaced  by 
loose,  dense,  fibrous  adhesions.  The  joint  cartilage  has  entirely  disappeared;  the 
trabeculee  of  the  phalanges  are  less  numerous  and  snialler  than  in  normal  bone. 
(Nichols  and  Richardson.) 

certain  forms  of  polyarthritis.  Notably  those  that  follow  infectious 
diseases.  A  form  of  subacute  artliritis  is  sometimes  observed  as 
a  complication  of  tuberculous  disease,  "tuberculous  rheumatism." 
There  are  other  forms,  for  example  arthritis  deformans,  gout  and 
the  like  in  which  defective  assimilation  and  lessened  resistance  are 
the  important  factors. 

HEMOPHILIA. 

Hemophilia  is  apparently  a  congenital  weakness  of  the  blood- 
vessels which  is  transmitted  through  females  to  males.  In  one 
family  under  observation  since  1827,  through  four  generations  (207 
members),  there  were  37  "bleeders,"  all  males;  33  per  cent,  of  the 
male  descendants.  Eighteeri  died  from  the  effects  of  hemorrhage, 
nearly  all  in  childhood.^  In  a  family  known  to  the  writer  all  the 
males,  3  in  number,  died  of  hemorrhage,  2  having  lived  to  adult 
age. 


1  Deutsch.  Ztschr.  f.  Chir.,  Ixxvi. 


TABETIC  ARTHROPATHY— CHARCOT'S  DISEASE         295 

Hemorrhage  into  a  joint  in  this  class  is  not  uncommon,  the  knee- 
joint  being  most  often  involved.  As  a  rule  it  is  the  result  of  injury, 
and  if  the  peculiarity  of  the  patient  is  known  the  nature  of  the 
effusion — hemorrhagic — is  hardly  doubtful,  particularly  as  there  are 
in  many  instances  discolorations  of  the  skin,  either  over  the  joint  or 
elsewhere.  In  some  instances  there  is  no  history  of  traumatism, 
and  the  swelling  may  be  accompanied  by  fever.  This  is  probably 
the  effect  of  the  hemorrhage  rather  than  its  cause. 

The  peculiar  interest  in  the  affection,  aside  from  the  importance 
of  a  proper  diagnosis,  lies  in  the  fact  that  the  further  organization 
of  the  effused  blood  may  cause  symptoms  and  changes  about  the 
joint  that  may  be  mistaken  for  those  of  tuberculous  disease.  There 
may  be,  for  example,  persistent  swelling,  thickening  of  the  tissues, 
limitation  of  motion,  and  deformity  combined  with  more  or  less 
weakness  and  discomfort.  These  symptoms  are  explained  by  the 
irritation  of  the  effused  blood  and  by  its  further  absorption  and 
organization,  which  necessitates  the  formation  and  growth  of  new 
bloodvessels;  practically,  a  granulation  tissue  is  formed  that  erodes 
the  cartilage  upon  which  the  fibrinous  deposits  rest.  These  sec- 
ondary changes  resemble  the  early  stage  of  hypertrophic  arthritis. 

Treatment. — The  local  treatment  is  rest  and  protection  com- 
bined with  stimulating  applications  to  hasten  the  absorption  of  the 
effused  blood.  Several  deaths  have  been  reported  from  hemorrhage 
after  operative  intervention  in  cases  in  which  the  affection  had  been 
mistaken  for  tuberculous  disease. 

HEMARTHROSIS. 

Hemorrhage  into  a  joint  may  occur  in  normal  individuals,  and 
its  presence  is  not  always  indicated  by  superficial  discoloration. 
The  swelling  is  more  resistant  than  is  the  ordinary  effusion,  and  it 
is  far  more  persistent.  This  suggests  the  advisability  of  incision 
and  removal  of  the  blood  clots  in  certain  instances  in  order  to  relieve 
the  joint  of  burden  of  their  organization  and  absorption. 

SCORBUTUS— SCURVY. 

This  affection  is  sometimes  attended  with  hemorrhage  into  and 
about  the  joints.  It  will  be  considered  in  connection  with  infantile 
rhachitis. 

TABETIC  ARTHROPATHY— CHARCOT'S    DISEASE. 

Disease  of  the  joints  caused  by  tabes  may  occur  in  two  forms,  a 
simple  chronic  synovitis  or  as  a  destructive  osteo-arthritis.  The 
latter  is  the  characteristic  form  known  as  Charcot's  disease. 


296 


NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 


Pathology. — It  resembles  somewhat  in  its  pathology  degenerative 
arthritis.  The  cartilage  degenerates,  and,  together  with  the  under- 
lying bone,  is  worn  away  by  the  movements  of  the  limb.  Accom- 
panying the  destructive  process  there  is  an  exaggerated  and  irregular 
formation  of  cartilage  and  bone  about  the  periphery  of  the  joint. 
The  synovial  membrane  is  hypertrophied,  and  may  be  covered  in 
places  with  calcareous  plates;  the  contents  of  the  joint  are  usually 
increased  in  quantity. 


Fig.  234. — Charcot's  disease  of  the  knee-joint  showing  the  characteristic  enlarge- 
ment and  outward  bowing.  A  useful  support  for  cases  of  this  character  is  illus- 
trated in  Fig.  236. 

The  joint  disease  often  appears  early  in  the  course  of  locomotor 
ataxia,  before  its  existence  is  suspected.  It  is  sometimes  caused 
directly  by  injury  but  the  predisposing  cause  is  the  loss  of  protec- 
tion due  to  the  hypotonia  of  the  muscles  and  to  the  attitude  of  hyper- 
extension  at  the  knees  which  is  often  habitual. 

In  246  cases  of  arthropathy  analyzed  by  Henderson^  54  of  the 
patients  were  in  the  preataxic  stage,  36  in  the  transitional,  and  in 
156  the  ataxia  was  well  marked. 

Charcot's  disease  is  said  to  affect  about  5  per  cent,  of  the  ataxic 
patients;  it  is  more  common  in  the  lower  extremity,  and  one  or 
more  joints  may  be  involved.  In  the  cases  tabulated  by  Flatow 
the  distribution  was  as  follows : 


iPath.  and  Bact.,  1905,  x. 


TABETIC  ARTHROPATHY— CHARCOT'S  DISEASE 

Knee 60;  in  13  cases  both  knees. 

Foot 30;  in    9  cases  both  feet. 

Hip 38;  in     9  cases  both  hips. 

Shoulder 27;  in    6  cases  both  shoulders. ^ 


297 


Fig.  235. — Charcot's  disease,  illustrating  the  destruction  and  new  formation  of  bone. 

Chipault^  notes  the  distribution  in  217  cases  as  follows: 

Knee 120 

.Hip 57 

Foot     . 40 

Fifteen  cases  of  Charcot's  disease  involving  the  spine  have  been 
reported.^ 

Symptoms. — The  symptoms  are  the  swelling  due  to  the  effusion, 
laxity  of  the  ligaments,  and  deformity.     There  is  practically  no  local 

1  Deutsch.  Chir.,   1900,  i,  28. 

2  Le  Dentu  et  Delbet:  Traite  de  Chir. 

'  Abadie:  Nouv.  Icon,  de  la  Salpetriore,  1900,  xiii;  Cornell;  Johns  Hopkins  Hosp. 
Bull.,  October,  1902. 


208         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

pain  or  sensitiveness,  and  the  patient's  chief  complaint  is  of  the  weak- 
ness and  distortion  of  the  limb.  In  certain  cases  the  progress 
of  the  affection  is  \'ery  rapid,  and  the  destruction  of  the  bone  may 
be  so  extensive  that  there  is  an  actual  luxation  at  the  affected 
joint. 

Diagnosis. — If  the  patient  is  known  to  have  locomotor  ataxia 
the  diagnosis  will  be  evident,  and  in  any  event  the  peculiar  enlarge- 
ment and  thickening  of  the  tissues,  together  with  the  excessive 
laxity  of  the  ligaments,  characteristic  of  this  affection,  which  has 
been  called  a  caricature  of  hypertrophic  artliiitis,  should  call  atten- 
tion to  the  disease  of  the  spinal  cord.  Of  this  the  diagnostic  symp- 
toms besides  the  ataxia  are  absence  of  tendon-jerks  in  the  lower 
extremities,  pain,  disorders  of  sensation  and  lessened  muscular  tone, 
genito-urinary  complications,  and  absence  of  reaction  of  the  pupils 
to  light.i 

Treatment. — The  treatment  of  the  local  disease  is  efficient 
support  to  prevent  progressive  distortion.  Excision  of  the  knee 
has  been  performed,  but  in  many  cases  the  bones  have  failed  to 
unite,  and  on  this  account  the  operation  is  contra-indicated.  Spon- 
taneous fracture  is  common  in  tabetic  patients,  both  of  the  upper 
and  lower  extremities. 

Disease  of  joints  secondary  to  other  forms  of  disease  of  the  nervous 
system  may  occur.  It  is  most  common  as  a  complication  of  syringo- 
myelia, in  which,  in  contrast  to  locomotor  ataxia,  the  joints  of  the 
upper  extremity  are  far  more  often  involved  than  of  the  lower 
(Borchard)."  The  symptoms  of  this  affection  are  loss  of  sensation 
to  pain  and  temperature,  disturbance  of  nutrition  and  muscular 
atrophy. 

In  Schlesinger's  cases  the  distribution  was  as  follows:^ 

Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot       .      .      .      .     ■ 7 

Other  joints 8 

97 

In  all  forms  of  joint  disease  secondary  to  affections  of  the  nervous 
system  the  mfluence  of  injury  on  the  ill-nom-ished  or  ill-protected 
part  is  recognized  in  the  causation  and  in  the  progress  of  the  dis- 
ease.   This  indicates  the  principles  of  local  treatment. 

1  According  to  Uhthoff  the  symptoms  of  tabes  in  order  of  frequency  are  as  follows : 

1.  Disturbances  in  sensibility  (in  the  widest  sense)        .      .  92  per  cent. 

2.  Lancinating  pains 85  " 

3.  Loss  in  patellar  reflex 83  '' 

4.  Argyll-Robertson  pupils 79  " 

5.  Romberg  phenomenon    .       . 71  " 

6.  Ataxia 55  " 

-  Deutsch.  Ztschr.  f.  Chir.,  1904,  Ixxii, 

2  Die  Syringomyelie,  Wien,   1895. 


ANCHYLOSIS  299 

ANCHYLOSIS. 

Anchylosis  implies  fixation  in  an  attitude  of  deformity,  and  the 
term  should  be  restricted  to  practical  fixation  caused  by  tissue 
changes  within  or  without  a  joint.  It  is,  however,  often  incor- 
rectly applied  to  limitation  of  motion,  such  as  may  be  caused,  for 
example,  by  muscular  spasm. 

Etiology  and  Pathology. — Anchylosis  is  usually  secondary  to  an 
infective  process  in  or  about  the  joint  during  which  adhesions  have 
formed  within  and  without  the  capsule.  If  deformity  has  been 
allowed  to  persist  the  muscles  on  the  contracted  side  are  structurally 
shortened.  If  the  cartilage  has  been  destroyed,  bony  union  or 
synostosis  often  results.  This  is  sometimes  called  true,  as  distin- 
guished from  false  or  fibrous,  anchylosis. 

The  latter  form,  which  is  far  the  more  common  in  youthful  patient^, 
may  be  caused  by  adhesions  between  the  folds  of  synovial  membrane, 
by  adhesions  and  contractions  of  the  capsular  and  other  ligaments, 
by  adhesions  between  the  tendons  and  their  sheaths,  by  the  general 
adhesions  and  contractions  caused  by  burrowing  abscesses,  and  by 
structural  shortening  of  the  muscles  when  the  deformity  has  per- 
sisted for  a  sufficient  time.  It  may  be  caused,  also,  by  fractures 
or  dislocations  or  by  marginal  exostoses. 

Prevention  and  Treatment. — The  danger  of  anchylosis  may  be 
lessened  by  the  proper  treatment  of  the  disease  of  which  it  is  a  result. 
Even  in  tuberculous  disease,  for  example,  motion  may  be  preserved 
in  many  instances  by  efficient  protection,  by  which  the  area  of  the 
disease  is  restricted  and  its  destructive  eftects  checked.  In  this 
class  of  cases  the  joint  should  be  fixed  during  the  progressive  stage 
of  the  disease,  in  the  attitude  in  which  anchylosis,  if  it  be  unavoid- 
able will  least  inconvenience  the  patient,  and,  if  possible,  efficient 
traction  should  be  employed  with  the  aim  of  separating  the  surfaces 
of  the  adjoining  bones. 

Formerly  it  was  believed  that  prolonged  fixation  of  a  diseased 
joint  would  of  itself  induce  anchylosis,  but  now  that  it  is  known  that 
final  limitation  of  motion  is  dependent  upon  the  severity  and  the 
dm-ation  of  the  disease,  prolonged  rest  is  believed  to  be  the  most 
efficient  means  of  assuring  movement. 

Although  long-continued  splinting  of  a  joint  causes  temporary 
fixation  yet,  as  a  rule,  functional  use  will  restore  all  the  motion  of 
which  the  part  is  capable. 

Passive  Motion. — When  the  acute  symptoms  have  subsided  the 
absorption  of  the  plastic  material  may  be  hastened  by  massage,  the 
hot-air  bath,  and  the  like,  and  by  carefully  regulated  passive  and 
active  movements.  Passive  congestion  after  the  method  of  Bier 
is  also  of  value.^     In  the  final  stage,  when  there  is  no  longer  evidence 

1  Blecher:  Deutsch.  Ztschr.  f.  Chir.,  Ix,  250. 


300 


NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 


of  active  disease,  forced  motion  under  anesthesia  may  be  of 
service  in  breaking  adhesions,  especially  if  these  are  without  the 
joint.  Passive  movements  that  cause  persistent  discomfort  or 
pain,  which  are  often  employed  in  the  treatment  of  stiff  joints,  even 
when  the  disease  is  active,  are  absolutely  contra-indicated.  If, 
however,  the  limb  during  the  coiu-se  of  the  disease  has  become 
deformed,  it  should  be  restored  to  its  proper  position  as  soon  as 
possible,  even  though  force  is  required.  This  treatment  is  indi- 
cated in  order  to  prevent  or  to  overcome  secondary  retraction  of  the 
muscles  and  fasciae. 


Fig.  236. — A  useful  form  of  brace  for  weak  knee,  in  which  the  range  of  motion  is 
regulated  by  means  of  an  adjustable  wheel.     (Shaffer.) 


Forcible  Correction. — ^The  class  of  cases  in  which  the  limb  has 
become  fixed  in  deformity  is  the  most  favorable  one  in  which  to 
perform  the  so-called  brisement  force,  because  the  rectification  of 
deformity  is  always  indicated,  and  in  accomplishing  this  there  is 
always  the  prospect  of  regaining  a  certain  degree  of  motion.  If, 
however,  there  is  no  deformity,  the  advisability  of  forced  movement 


ANCHYLOSIS 


301 


will  depend  on  the  character  of  the  preceding  disease  as  well  as 
upon  the  condition  of  the  joint.  It  is  rarely  advisable  to  disturb 
a  tuberculous  joint  except  for  the  purpose  of  correcting  deformity, 
at  least  not  until  long  after  the  cure  of  the  disease;  but  if  the  fixa- 
tion has  followed  infectious  arthritis  of  a  mild  form,  or  monarticular 
"rheumatism,"  forcible  manipulation  may  be  attempted.    If  under 


Fig.  237. — Anchylosis  at  the  hip,  showing  masses  of  new  bone.     (From  the 
Museum  of  the  College  of  Physicians  and  Surgeons.) 

gentle  manipulation  the  adhesions  give  way  suddenly,  permitting 
free  motion,  the  prognosis  is  good;  but  if  there  is  a  peculiar,  elastic, 
continuous  resistance,  as  when  there  are  extensive  adhesions  within 
the  joint,  there  is  little  likelihood  of  attaining  motion  by  this  means. 
If  but  slight  force  has  been  exerted  there  is  usually  but  little  reac- 
tion, and  massage  and  passive  movement  may  be  employed  at  once ; 


302         XOX-TUBERCULOrS  DISEASES  OF   THE  JOIXTS 

but  in  other  instances  the  manipulation  is  foUowed  by  swelHng 
and  pain,  and  until  these  s^iTnptoms  have  subsided  fixation  may  be 
mdicated.  It  may  be  mentioned  that  anchylosis  folloTving  disease 
is  usually  accompanied  by  marked  atrophy  of  the  bones,  and  frac- 
tm'e  may  occur  durmg  forcible  correction.  In  cases  of  this  charac- 
ter the  complication  of  fat  embolism  is  sometimes  encountered. 
If  the  deformity  is  of  long  standing,  complete  correction  should 
not  be  attempted  at  one  sitting.  At  the  knee,  for  example,  the  ham- 
string tendons  may  be  divided,  and  the  deformity  having  been 
partly  corrected,  a  plaster  bandage  should  be  applied.  After  an 
interval  of  a  week  or  more  fm'ther  correction  is  attempted  by 
"reverse  leverage"  as  described  elsewhere.  If  the  resistance  can- 
not be  readily  overcome  a  subcutaneous  osteotome  is  inserted  just 
above  the  joint  and  the  correction  is  made  complete  by  fracturing 
the  femur.  In  cases  of  bony  anchylosis  m  youthful  patients  even 
right  angular  deformity  should  be  corrected  by  osteotomy  rather 
than  by  removal  of  a  wedge  of  bone  which  must  include  the 
epiphyseal  cartilages. 

After  subsidence  of  tlie  reaction  that  usually  follows  forcible 
correction,  passive  movements  ^"ithm  the  range  that  is  practically 
painless  may  be  carried  out  manually,  or  by  means  of  one  of  the 
so-called  pendulum  machines,  by  which  the  limb  is  moved  back 
and  forth  thi-ough  an  arc  unrestrained  by  muscular  spasm.  Func- 
tional use,  when  the  joint  is  protected  by  apparatus  that  limits  the 
range  of  motion  to  the  painless  area,  is  also  of  service. 

The  .r-rays  are  of  value  in  demonstrating  the  condition  of  the  joint 
and  the  degree  of  atrophy  of  the  bones,  but  the  history,  which 
should  indicate  the  character  of  the  disease,  and  the  physical 
exammation  are  far  more  reliable  from  the  stand-point  of  prognosis. 
In  some  instances  operative  exploration  of  the  joint  may  be  indi- 
cated. This  permits  the  removal  of  exostoses  or  displaced  frag- 
ments of  bone  after  fractiu'e  that  may  limit  motion  mechanically. 

Artheoplasty. — Operations  for  the  restoration  of  motion  in 
anchylosed  joints  are  conducted  on  the  foUowuig  principles: 

Sufficient  bone  must  be  removed  to  leave  a  wide  interval  between 
the  opposing  sm'faces  in  wliich  tissue  may  be  mserted  to  prevent 
reunion.  The  bones  should  be  modeled  to  assure  stability,  preserv- 
ing as  far  as  possible  the  normal  outline,  especially  at  the  elbow- 
and  knee-joints.  The  most  favorable  cases  for  operation  are  those 
of  complete  bony  union.  The  most  unfavorable  are  those  in  which 
the  bone  is  atrophied  and  degenerated  as  after  tuberculous  disease. 

Arthroplasty  is  most  often  indicated  in  the  upper  extremity 
where  motion  is  more  important  than  stability.  At  the  shoulder- 
joint  even  complete  resection  of  the  head  of  the  humerus  does  not 
prevent  useful  function.  At  the  elbow,  stability  is  essential  to 
useful  function.  In  the  lower  extremity  security  in  weight-bearing 
in  the  laboring  classes  has  far  greater  importance  than  movement. 


ANCHYLOSIS  303 

The  ankle-joint  offers  the  most  favorable  prognosis,  because 
motion  may  be  usually  assured  by  removal  of  the  astragalus  without 
loss  of  stability. 

At  the  hip  the  most  direct  indication  for  operation  is  bilateral 
anchylosis,  when  bony  union  on  one  side  is  accompanied  by  marked 
deformity. 

The  head  of  the  bone  may  be  very  much  reduced  in  size  or  even 
resected  and,  yet  stability  assured  if  the  trochanter  is  displaced 
outward  and  downward  to  permit  complete  inclusion  of  the  neck 
within  the  acetabulum. 

The  prospect  of  painless  controlled  movement  combined  with 
stability  is  most  unfavorable  at  the  knee-joint,  and  the  operation 
should  be  undertaken  only  in  those  cases  in  which  the  ability  to 
flex  the  limb  in  the  sitting  posture  is  of  greater  moment  than  security. 

The  most  favorable  cases  are  those  in  which  articulation  permits 
motion  which  is  restrained  by  an  adherent  patella. 

Success  in  arthroplasty  in  cases  in  which  the  joint  surfaces  are 
destroyed  is  primarily  dependent  on  the  removal  of  sufficient  bone. 
An  interval  of  one-half  inch  between  the  opposing  surfaces  is 
necessary,  and  all  the  tissue  that  may  restrain  such  separation 
should  be  removed.  Union  of  the  denuded  surfaces  is  prevented  by 
flaps  of  fatty,  fibrous  or  muscular  tissue  from  the  neighborhood, 
or  fascia  may  be  transplanted  from  the  outer  and  upper  third  of  the 
thigh,  or  foreign  substances,  such  as  chromicized  pig's  bladder 
(Baer)  may  be  used. 

The  first  method  is  more  applicable  at  the  shoulder-  and  hip- 
joints.  It  has  the  disadvantage  of  difficulty  in  adjustment  and  at 
other  joints  the  tissues  are  often  so  atrophied  that  the  material 
is  insufficient;  furthermore  sloughing  of  the  skin  may  follow  exten- 
sive dissection  for  this  purpose. 

At  the  knee-joint.  Murphy  removes  bone  practically  entirely 
from  the  tibia,  following  the  normal  contour  and  covers  the  denuded 
surface  by  lateral  flaps  made  from  the  capsular  ligament  which  is 
detached  from  the  femur. 

The  interposition  of  foreign  substances  necessitates  absorption 
or  extrusion,  and  the  most  practicable  method  is  the  transplanta- 
tion of  a  covering  of  sufficient  size  from  the  thick  fascia  of  the  thigh. 
This  may.  be  accurately  adjusted  and  sewed  about  the  exposed 
bone  and,  as  a  rule,  it  causes  no  subsequent  disturbance. 

The  joint  should  be  fixed,  preferably  by  a  traction  splint  to  keep 
the  bones  apart  for  a  time  sufficient  to  prevent  repair,  when  passive 
and  active  movements  should  be  begun.  The  eventual  success  is 
in  great  degree  dependent  on  the  after-treatment. 

Klapp^  has  called  attention  to  the  fact  that  at  the  knee-joint  the 
cartilage  on  the  posterior  aspect  of  the  condyles  may  be  in  fairly 

1  Ztschr.  f.  Chir.,  July  30,  1910. 


304         NON-TUBERCULOUS  DISEASES  OF   THE  JOINTS 

healthy  condition.  In  such  cases  the  tibia  is  forcibly  flexed  to  a 
right  angle  in  apposition  to  this  surface,  and  by  removal  of  a  suffi- 
cient wedge  of  bone  from  the  front  of  the  lower  extremity  of  the 
femur  the  tibia  is  brought  to  the  axis  of  the  limb,  still  preserving 
its  right  angular  relation  in  the  articulation.  Such  an  operation 
must  include,  of  course,  the  freeing  of  the  patella  if  it  is  adherent 
to  the  bone. 

MALIGNANT   DISEASE    OF   BONE. 

Carcinoma  is  almost  always  secondary  to  disease  elsewhere  as 
of  the  breast  or  genito-urinary  organs.  Sarcoma  is  usually  a  pri- 
mary disease.  Its  seat  of  election  is  near  the  extremities  of  the 
long  bones,  thus  it  is  often  mistaken  for  disease  of  the  neighboring 
joint.  It  is  far  more  common  in  the  lower  than  in  the  upper  extrem- 
ity and  in  50  per  cent,  of  the  cases  the  femur  is  involved.^ 

The  tumor  may  be  periosteal  or  central.  If  periosteal  its  outline 
is  irregular.  If  central  the  bone  is  more  uniformly  enlarged.  In 
some  instances,  the  pain,  sensitiveness  and  swelling  induced  appar- 
ently by  injury  simulate  very  closely  disease  of  the  joint.  As  a 
rule,  however,  the  disease  of  the  bone  is  more  marked  than  that  of 
the  joint,  and  an  a'-ray  picture  will  indicate  its  destructive  character. 

1  Coley:  Ann.  Surg.,  March,  1907. 


CHAPTER   VII. 
TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 

Synonyms. — Hip  disease,  morbus  coxse. 

Hip  disease  is  a  chronic  destructive  disease  that  results  in  loss 
of  function  and  deformity.  At  one  time  a  number  of  pathological 
processes  and  even  simple  deformity  (coxa  vara)  were  included 
under  the  title,  but  it  is  now  limited  to  tuberculous  disease. 


Fig.  238. — Section  of  the  hip-joint  at  the  age  of  eight  years,  showing  the  epiphyses 
and  the  relation  of  the  capsule.  (Schuchardt.)  At  birth  the  entire  upper  extremity 
of  the  femur  is  cartilaginous.  According  to  Jacinsky,  ossification  begins  in  the  head 
of  the  femur  at  about  the  tenth  month;  in  the  trochanter  major  at  from  the  fourth 
to,  the  eighth  year;  in  the  trochanter  minor  at  the  eleventh  year.  Ossification  is 
complete  at  all  points  at  about  the  eighteenth  year. 

Range  of  motion  at  the  hip-joint.  Extension  to  20  degrees  beyond  the  horizontal; 
flexion  to  70  degrees;  total  140  degrees.  Abduction,  adduction,  and  rotation  are 
most  free  when  the  limb  is  flexed  to  13  degrees.  At  this  point  the  range  of  abduc- 
tion is  55  degrees,  of  adduction  35  degrees;  total  90  degrees.  Outward  rotation  40 
degrees,  inward  rotation  20  degrees;  total  60  degrees.  If  the  limb  is  completely 
extended  the  range  of  abduction  is  about  45  degrees;  adduction,  15  degrees. ^ 

Pathology. — ^Tuberculous  disease  of  the  hip-joint  of  the  classical 
type  usually  begins  in  several  minute  foci  near  the  epiphyseal  car- 
tilage of  the  head  of  the  femur.  Here  the  circulation  is  most  active, 
and  here  the  newly  formed  bone  is  least  resistant.     Thus  the  bacilli, 

1  R.  du  Bois-Raymond:  Berlin,  1903. 
20 


306 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


carried  by  the  blood,  are  more  often  deposited  at  this  point,  where, 
under  favoring  conditions,  the  disease  is  estabhshed.  These  foci 
coalesce  and  an  area  of  infected  granulations  replaces  the  normal 
structure.  If  the  local  resistance  is  sufficient  the  disease  may  be 
confined  to  the  interior  of  the  bone,  but  in  most  instances  it  gradu- 
ally forces  its  way  into  the  joint  and  the  granulation  tissue,  spreading 
under  and  over  the  cartilage,  destroys  it  in  its  progress.  The  lining 
membrane  of  the  joint  becomes  involved  in  the  disease,  and,  finally, 
the  adjoining  surface  of  the  acetabulum  as  well.     In  other  instances 

the  tuberculous  process  may 
begin  about  the  epiphyseal 
junctions  of  the  acetabulum, 
or  primarily  in  the  synovial 
membrane,  although  this  is 
apparently  uncommon  in  child- 
hood. 

Waldenstrom,^  from  obser- 
vations on  83  cases  of  hip  dis- 
ease, nearly  all  in  children, 
concludes  that  the  primary 
infection  was  apparently  of 
the  neck  of  the  femur  in  22, 
of  the  head  in  3,  of  the  acetab- 
ulum in  28,  of  the  synovial 
membrane  in  15,  and  inde- 
determinate  in  15.  Of  the  22 
cases  in  which  the  neck  was  in- 
vohed,  the  disease  was  near 
the  upper  border  in  7,  the 
lower  border  in  15.  In  14  in- 
stances the  disease  was  con- 
fined to  the  neck.  Kepler  and 
Erkes,-  on  the  other  hand,  in 
235  cases  found  the  primary 
focus  in  the  neck  in  8  per 
cent.,  in  the  acetabulum  in 
11  per  cent,  and  in  the  head 
per  cent.,  which  accords  with  the  generally 


) 


Fig.  239. — "Waudering    of    the    acetab- 
ulum" in  hip  disease.      (Krause.) 


of  the   femur  in 
accepted  opinion. 

From  the  clinical  stand-point,  primary  disease  of  the  acetabulum 
may  be  inferred  if  the  patient  is  particularly  susceptible  to  move- 
ments of  the  trunk,  or  if  lateral  pressure  on  the  pelvis  causes  pain; 
or  if  a  Roentgen  picture  shows  greater  erosion  of  the  acetabulum 
than  of  the  head  of  the  femur.  If  the  disease  is  confined  to  the 
neck,  the  symptoms  are  less  distinctive  and  deformity  (coxa  vara) 

1  Stockhohn,  1910. 

2  Arch.  f.  klin.  Chir.,  1914,  Band  cv,  Heft  3. 


PATHOLOGY 


307 


may  be  an  early  indication  of  weakness.  There  are  cases  in  which 
the  symptoms  of  the  disease  are  sHght  and  in  which  swelhng 
about  the  joint  is  noticeable;  in  such  cases  it  is  probable  that  disease 
of  the  synovial  membrane  is  present  without  marked  involvement 
of  the  head  of  the  femur  or  of  the  acetabulum. 

In  the  common  or  osteal  form  of  disease,  while  the  tuberculous 
process  is  still  confined  within  the  head  of  the  femur,  the  joint  shows 
evidences* of  sympathetic  irritation;  the  synovial  membrane  is 
congested,  and  the  fluid  within  the  joint  is  increased  in  quantity. 
These  changes  become  more  marked  as  the  disease  progresses,  the 


Fig.  240. — Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of  the  acetab- 
ulum.    Formation  of  new  bone  (osteophytes)  about  the  acetabulum. 

lining  membrane  becomes  thickened  and  granular,  and  adhesions 
between  its  folds  lessen  the  capacity  of  the  joint.  An  amount  of 
tuberculous  fluid,  large  enough  to  be  recognized  as  an  "abscess," 
is  present  in  about  half  the  cases  at  some  time  during  the  course  of 
the  disease.  This  fluid  usually  flnds  an  exit  from  the  capsule  into 
the  tissues  of  the  thigh,  but  occasionally  it  may  pass  through  the 
acetabulum  into  the  pelvis.  In  rare  instances  the  disease  may  not 
enter  the  joint,  but  may  find  an  opening  in  the  neck  through  the 
adherent  capsule.  In  such  cases  the  joint  is,  in  most  instances, 
finally  involved  unless  the  disease  is  removed  by  surgical  means. 
There  are  cases,  also,  in  which  the  disease,  confined  within  the  head 


308  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

of  the  bone,  so  weakens  it  that  it  becomes  distorted  to  a  marked 
degree  without  destruction  of  the  cartilage. 

If  the  disease  involves  the  neck  of  the  bone  its  angle  may  diminish, 
a  form  of  coxa  vara;  or  the  head  of  the  bone  may  be  separated  at 
the  epiphyseal  junction,  with  consequent  upward  displacement  of 
the  shaft. 

In  by  far  the  larger  number  of  cases  all  the  tissues  of  the  joint  are 
involved  and  the  head  of  the  femur  and  the  acetabulum  are  eroded 
to  a  greater  or  less  degree.  In  such  instances  the  destructive  effects 
of  the  disease  are  increased  by  the  pressure  and  friction  of  the 
softened  bones  on  one  another,  aggravated  by  the  spasm  of  the 


^M 

■■ 

1 

m 

1> 

^H 

^M 

^^^^^p 

1 

f 

T      ■ 

i 

^^^^^1 

^^1 

^M 

^Hr'^ 

^A 

£. 

fi-% 

^  ^^^1 

^^1 

B 

^^m 

M 

m 

mt 

'^i^^l 

B 

^^^S 

1 

^^^^T'-* 

mi/i 

^^^S^a 

1 

■^^1 

Fig.   241. — Erosion  of  the  head  of  the  femur  and  of  the  upper  margin  of  the  acetab- 
ulum.    A,  anterosuperior  spine.     B,  antero-inferior  spine. 

controlling  muscles.  Thus  at  the  upper  margin  of  the  acetabuliun 
and  the  inner  and  upper  surface  of  the  femur  there  is  greater  loss 
of  substance  than  elsewhere  (Fig.  241). 

The  appearances  in  advanced  cases  of  this  type,  as  seen  at  opera- 
tion or  autopsy,  may  be  summarized  as  follows:  The  head  of  the 
femur  is  deeply  eroded,  its  cartilaginous  covering  has  practically 
disappeared,  or  is  in  part  still  adherent  in  necrotic  shreds.  It  lies 
in  seropurulent  fluid,  embedded  in  the  gelatinous  granulations  that 
line  the  capsule  and  partly  fiU  the  acetabulum. 

In  certain  instances  the  disease  may  extend  to  the  adjoining  sur- 
face of  the  pelvis,  or  the  acetabulum  may  be  perforated  (Fig.  242), 
or  the  medullary  cavity  of  the  femur  may  be  implicated.     Occa- 


ETIOLOGY 


309 


sionaliy  the  disease  may  be  from  the  first  of  an  acute  destructive 
type,  whose  course  is  but  Httle  influenced  by  treatment,  but  in  the 
majority  of  cases  the  progress  of  the  disease  and  its  destructive 
effects  may  be  greatly  modified  by  efficient  protection  of  the  joint. 

In  the  natural  cure  of  the  disease  the  focus  within  the  bone,  if  it 
be  small,  may  be  absorbed  and  replaced  by  scar-like  tissue;  or  the 
products  of  the  disease  may  be  separated  from  the  healthy  parts, 
and  dischafged  by  abscess  formation.  In  other  instances  a  part  in 
which  the  disease  is  still  active  may  be  enclosed  within  the  newly 
formed  tissue.  Here  the 
process  may  remain  qui- 
escent or  it  may  cause  re- 
lapse many  years  after 
the  apparent  cure.  Or 
portions  of  necrosed  bone, 
enclosed  within  the  cap- 
sule, may  prolong  suppura- 
tion after  the  tuberculous 
disease,  has  ceased  to  pro- 
gress. 

Etiology. — The  etiology 
of  tuberculous  disease  is 
discussed  in  Chapter  V. 

Relative  Frequency.  — 
Tuberculous  disease  of  the 
hip-joint  is  the  most  com- 
mon and  the  most  impor- 
tant of  the  affections  of 
the  joints,  ranking  second 
to    Pott's    disease.     In    a 

total  of  7845  cases  of  tuberculous  disease  treated  in  the  out-patient 
department  of  the  Hospital  for  Ruptured  and  Crippled  during  a 
period  of  fifteen  years  3203  were  Pott's  disease,  2230  were  hip  dis- 
ease, while  the  remaining  2412  cases  included  all  the  other  joints. 


Fig.  242. — Erosion  of  the  head  of  the  femur 
and  destruction  of  the  acetabulum. 


Age  at  Incipiency. 


Less  than  1  year      .... 

9 

Between 

1  and    2  years    . 

39 

Between 

2  and    3  years    . 

107 

Between 

3  and    4  years    . 

155 

Between 

4  and    5  years    . 

158 

Between 

5  and    6  years    . 

139 

Between 

6  and    7  years    . 

90 

Between 

7  and    8  years    . 

51 

Between 

8  and    9  years   . 

51 

Between 

9  and  10  years    . 

40 

Between  10  and  11  years    . 

33 

Between  11  and  12  years    . 

19 

Between  12  and  13  years    . 

18 

Between  13  and  14  years    . 

23 

Between  14  and  15  years    . 

7 

Between  15  and  16  years    . 

8 

Between  16  and  17  years 
Between  17  and  18  years 
Between  18  and  19  years 
Between  19  and  20  years 
Between  20  and  21  years 
Between  21  and  22  years 
Between  22  and  23  years 
Between  23  and  24  years 
Between  24  and  25  years 
Between  25  and  26  years 
Between  26  and  27  years 
Between  27  and  28  years 
Between  28  and  29  years 
Between  30  and  33  years 
Between  33  and  36  years 
Age  not  stated    . 


14 
1 
5 
0 
3 
3 
1 
2 
3 
1 
1 
1 
1 
4 
1 

12 


1000 


310  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

Age. — Hip  disease  is  essentially  a  disease  of  early  childhood, 
although  no  age  is  exempt.  In  a  series  of  1000  consecutive  cases 
of  hip  disease  tabulated  for  me  by  Ashley,  formerly  an  assistant  in 
the  department,  88.1  per  cent,  of  the  patients  were  in  the  first 
decade  of  life,  and  45.6  per  cent,  of  these  were  from  three  to  five 
years  of  age,  inclusive. 

Sex. — Sex  exercises  but  little  influence  in  predisposition,  although 
the  disease  is  slightly  more  common  among  males  than  among 
females.  In  the  1000  cases  referred  to,  553  (55.3  per  cent.)  were 
in  males,  447  were  in  females.  In  3307  cases  treated  at  the  same 
institution,  53  per  cent,  were  in  males. 

Side  Affected. — In  disease  of  this  as  of  other  joints  the  right  is 
somewhat  more  often  affected  than  the  left.  In  the  1000  cases 
506  were  on  the  right  side,  483  were  on  the  left,  and  in  11  cases  both 
joints  were  involved.  In  a  larger  niunber  of  cases  treated  in  the 
department  53  per  cent,  were  of  the  right  joint. 

Symptoms. — Tuberculous  disease  of  the  hip-joint  is  a  chronic, 
insidious  affection  characterized  by  painful  periods  often  induced 
by  overstrain  or  injury,  or  that  indicate  more  rapid  advance  of  the 
destructive  process,  or  infection  with  pyogenic  germs.  In  the  early 
stage  of  the  disease  the  joint  is  simply  sensitive,  and  the  s^TQptoms 
vary  with  the  increase  of  the  tension  withm  the  bone,  the  suscepti- 
bility of  the  patient,  and  the  strain  to  which  the  weakened  part  is 
subjected.  This  sensitiveness  is  first  indicated  by  the  involuntary 
adaptation  of  the  body  to  the  weakness  of  the  affected  joint,  or,  as 
popularly  expressed,  the  patient  favors  the  limb. 

The  important  symptoms  of  disease  of  the  hip-joint,  in  the  sense 
of  attracting  attention  to  the  affection,  are  pain  and  limp.  Of  the 
two,  pain  is  much  the  less  significant.  Hip  disease  is  by  no  means 
a  painful  disease,  and  although  patients  are  often  brought  for  treat- 
ment because  of  pain,  it  is  usually  apparent,  on  examination,  that 
the  disease  must  have  existed  long  before  the  acute  exacerbation 
called  attention  to  its  serious  character.  Even  in  cases  in  which  the 
disease  is  far  advanced,  one  may  be  assiu-ed  that  the  patient  has 
never  complained  of  pain. 

Pain. — The  characteristic  pain  of  hip  disease  is  "  pain  in  the  knee," 
referred,  as  is  the  pain  of  Pott's  disease,  to  the  more  unportant  dis- 
tribution of  the  nerves,  whose  filaments  are  irritated  by  the  local 
process.  The  hip-joint  is  supplied  by  the  gluteal,  the  anterior 
crural,  the  sciatic,  and  the  obturator  nerves,  but  the  pain  is  more 
often  referred  to  the  distribution  of  the  last,  thus  to  the  mner  side 
of  the  knee. 

The  pain  of  hip  disease  is  induced  by  sudden  or  unguarded  move- 
ments, or  by  overuse;  therefore  it  is  rather  an  occasional  than  a 
constant  symptom.  If  it  is  persistent  it  almost  always  indicates 
the  increased  tension  either  within  the  bone  or  within  the  joint  that 
accompanies  abscess  formation. 


PHYSICAL  SIGNS  311 

Night  Cry. — Pain  at  night  is  of  importance,  as  it  more  often 
attracts  attention  than  the  occasional  complaint  of  discomfort 
during  the  day.  It  is  a  common  symptom  when  the  disease  is  at  all 
acute  in  character,  and  it  is  often  present  when  pain,  during  the 
period  of  activity,  is  apparently  absent.  It  may  be  inferred,  as  an 
explanation  of  this  symptom,  that  the  joint  gradually  becomes  more 
sensitive  under  the  strain  of  use  during  the  day,  and  that  the  relax- 
ation of  the  voluntary  and  involuntary  protection  of  the  muscles 
permits  sudden  movements  that  excite  spasmodic  muscular  contrac- 
tions, wjiich  force  the  sensitive  parts  against  one  another.  This 
causes  a  sharp  cry.  If  the  disease  is  acute,  it  may  be  noted  that  the 
child  is  holding  the  thigh  with  the  hands  or  pressing  upon  the  limb 
the  other  foot,  the  evidence  of  pain  being  unmistakable.  In  the 
less  sensitive  conditions  the  patient  does  not  wake  after  crying  out, 
but  simply  moans  or  is  restless  for  a  time.  If  awakened  it  makes 
no  complaint  of  pain  and  the  cry  is  supposed  to  be  caused  by  a  "  bad 
dream."  This  cry  may  be  repeated  several  times,  usually  in  the 
early  part  of  the  night. 

Local  pain  and  sensitiveness  to  pressure  are  unusual  unless  the 
disease  is  acute  in  character,  or  unless  the  tissues  overlying  the  joint 
are  infiltrated,  as  in  abscess  formation. 

Limp. — The  limp  is  the  most  important  of  what  may  be  classed 
as  the  preliminary  signs  of  the  disease.  A  limp  is  a  change  in  the 
rhythm  of  the  gait,  the  step  being  relatively  shorter  on  the  affected 
side.  It  is  evident  that  any  interference  with  the  function  of  the 
limb  will  cause  this  irregularity  which  can  be  concealed  or  dimin- 
ished only  by  accommodating  the  normal  member  to  its  disabled 
fellow.  Thus  inequality  in  length  of  the  limbs  or  limitation  of 
motion  in  the  joint,  or  distortion,  or  weakness  or  pain,  may  cause  an 
arrhythmical  gait.  Several  of  these  factors  may  be  combined  in 
the  causation  of  the  final  disability  of  hip  disease,  but  in  the  begin- 
ning the  limp  is  due  rather  to  sensitiveness  than  to  restriction  of 
function.  Thus  the  patient  favors  the  joint  by  resting  on  the  limb 
for  a  shorter  time  than  on  its  fellow,  and  by  bearing  more  weight 
upon  the  front  of  the  foot  than  upon  the  heel.  If  the  joint  is  very 
sensitive,  the  patient  may  bear  practically  all  the  weight  upon  the 
front  of  the  foot,  the  slight  plantar  flexion  at  the  ankle  with  flexion 
at  the  knee  and  hip  lessening  the  jar  of  direct  impact. 

The  limp  is  practically  a  constant  symptom  of  hip  disease ;  it  is, 
as  a  rule,  more  noticeable  in  the  morning  or  on  changing  from  an 
attitude  of  rest  than  during  activity.  It  may  be  intermittent 
even  though  it  is  probable  that  in  most  instances  some  change 
from  the  normal  gait  might  be  detected  by  a  practised  eye. 

Physical  Signs. — The  other  symptoms  of  disease  of  the  hip- 
joint  are  more  properly  physical  signs  that  become  evident  on  exami- 
nation. These  are:  Limitation  of  motion,  distortion,  change  of  con- 
tour, and  atrophy. 


312  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

Stiffness. — Limited  motion  ('"stiffness"),  due  to  reflex  muscular 
spasm,  is  by  far  the  most  important  sign  of  the  disease.  It 
indicates  that  the  sensitive  tissues  of  the  joint  can  no  longer  permit 
the  normal  range.  It  is  the  first  and  the  last  sign  of  disease;  it  pre- 
cedes the  limp,  and  it  persists  long  after  pain  has  ceased  to  be  a 
symptom,  and  until  repair  is  complete. 

Reflex  muscular  spasm  Iknits  motion  in  every  direction.  At  an 
early  stage  of  the  disease  the  motion,  whether  vohmtary  or  passive, 
may  be  perfectly  free  to  the  last  quarter  of  its  normal  range,  where 
it  is  checked  by  a  peculiar  elastic  resistance.  If  an  attempt  is  made 
to  force  the  limb  beyond  the  limit  set  by  the  muscular  resistance 
the  pelvis  follows  the  movement.  The  contraction  of  the  surround- 
ing muscles,  including  those  of  the  trunk  even,  may  be  appreciated 
by  the  eye  and  by  the  hand,  and  the  patient's  expression  is  one  of 
discomfort  and  apprehension. 

The  degree  of  muscular  spasm  corresponds  to  the  sensitiveness 
of  the  joint  rather  than  to  the  extent  of  the  disease.  Thus  it  may 
vary  from  day  to  day  and  even  from  hour  to  hour,  and  in  the  acute 
phases  of  the  disease  motion  may  be  for  a  time  so  absolutely 
restricted  as  to  simulate  anchylosis. 

Reflex  muscular  spasm  is  evidence  of  a  sensitive  joint;  it  is,  of 
course,  not  diagnostic  of  the  tuberculous  process,  but  unless  it  is 
the  direct  eftect  of  mjury  it  indicates  disease,  and  if  this  disease  is 
chronic  and  confined  to  a  single  joint  it  is,  in  childhood  at  least, 
almost  always  tuberculous  in  character.  At  first  the  restriction  of 
motion  is  caused  almost  entirely  by  reflex  muscular  spasm,  as  is 
shown  by  the  fact  that  when  the  patient  is  anesthetized  the  range 
of  motion  becomes  practically  free.  As  the  destructive  process 
progresses  motion  is  still  further  restrained  by  adhesions  and  con- 
tractions within  and  without  the  joint. 

Distortion  of  the  Limb. — Persistent  reflex  muscular  spasm  is 
always  accompanied  by  a  certain  change  in  the  attitude  of  the  limb, 
slight  flexion  being  the  earliest  indication  of  distortion  here  as  at 
every  other  joint.  With  flexion  there  is  usually  abduction  with 
slight  outward  rotation  of  the  limb. 

Flexion,  Abductiox,  and  Outwaed  Rotation.  Apparent 
Lengthening. — This  is  the  passive  attitude  or  the  attitude  of  rest 
and  m  disease  it  shows  the  instinctive  adaptation  of  the  limb  to  a 
sensitive  joint.  Flexion  lessens  the  direct  jar  and  abduction  places 
the  limb  aside,  as  it  were,  making  it  a  prop  and  adjunct  of  its  fellow 
instead  of  an  active  aid  in  the  propulsion  of  the  body.  This  atti- 
tude is  not  voluntarily  assumed  by  the  patient;  it  is  involuntary 
and  persistant.  The  limb  is  apparently  lengthened,  because  it  is 
held  away  from  the  axis  of  the  body,  and  in  order  to  bring  it  into  the 
middle  line  and  parallel  to  its  fellow  the  pelvis  must  be  tilted  do^\Ti- 
ward  on  the  diseased  side  and  upward  on  the  other.  The  sound 
limb  is  drawn  upward  and  the  affected  limb  is  lowered  according  to 


PHYSICAL  SIGNS 


313 


the  degree  of  abduction  for  which  compensation  is  made  (Fig.  244). 
If  the  anterosuperior  spines  of  the  pelvis  are  placed  upon  the  same 
plane,  the  distortion  becomes  evident  (Fig.  243) .  Thus  the  deformity 
of  the  limb  is  concealed  or  compensated  by  a  tilting  of  the  pelvis 
which  twists  the  lumbar  spine  into  a  lateral  convexity  toward  the 
lower  side. 


Fig.  243. — Apparent  lengthening.  Fixed  abduction  of  45°.  When  the  antero- 
superior spines  are  on  the  same  plane,  as  in  the  illustration,  the  deformity  is  evident. 
(See  Fig.  244.) 

In  the  same  manner  persistent  flexion  of  the  limb  is  concealed 
by  tilting  of  the  pelvis  forward,  and  by  an  increased  hollowness  or 
lordosis  of  the  lumbar  region  (Fig.  245).  Normally,  in  childhood 
at  least,  the  lumbar  spine  and  the  popliteal  surface  of  the  knee 
should  touch  the  table  when  the  patient  lies  upon  the  'back;  but  if 
the  thigh  is  fixed  in  flexion  the  lumbar  region  must  be  arched  and 
raised  from  the  table  when  the  limb  is  in  contact  with  it.     Thus  in 


J14 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


order  to  make  the  flexion  apparent,  the  himbar  spme  must  rest  upon 
the  table,  and  this  is  possible  only  when  the  limb  is  raised  to  a  degree 
corresponding  to  the  deformity  (Fig.  246).  If  the  spine  were  rigid, 
as  in  spondylitis  deformans,  this  compensation  would  be  impossible, 
and  if  the  patient  were  placed  upon  his  back  the  limb  could  not  be 
brought  down  to  the  table;  or  if  both  limbs  were  distorted, 


as  is 


Fig.  244. — Apparent  lengthening. 
When  the  abducted  limb  is  brought  to 
the  median  line  the  peh-is  is  so  tilted 
that  it  seems  longer.     (See  Fig.  243.) 


Fig.  245. — Right  angular  flexion  in 
hip  disease  partly  concealed  by  the 
compensatory  lordosis  and  by  the 
flexion  at  the  knee  and  ankle. 


sometimes  the  case  when  both  hip-joints  are  diseased,  the  limbs 
would  remain  widely  separated  or  crossed  over  one  another,  accord- 
ing to  the  character  of  the  deformity. 

Flexion,  Adduction,  and  In^'ard  Rotation.  Apparent 
Shortening. — If  the  disease  is  of  a  more  acute  type,  and  if  loco- 
motion be  permitted,  the  attitude  usually  changes  to  one  of  increased 


PHYSICAL  SIGNS  315 

flexion,  and  adduction  and  inward  rotation  replace  abduction  and 
outward  rotation.  This  attitude  is  an  indication  that  the  joint  is 
so  disabled  as  to  be  of  little  service,  thus  the  limb  is  instinctively 
drawn  into  a  more  protected  attitude,  where  it  may  be  used  as  little 
as  possible.  If  the  patient  is  confined  to  the  bed,  or  does  not  walk, 
as  in  infancy,  the  attitude  of  abduction  may  persist,  although  the 
muscular  spasm  may  be  intense.  Thus  it  would  appear  that  loco- 
motion has  a  distinct  influence  on  the  character  of  the  distortion. 

Adduction  causes  apparent  or  practical  shortening,  for  in  order 
to  bring  the  adducted  limb  to  the  middle  line  of  the  body  and  parallel 
to  its  fellow,  the  pelvis  must  be  tilted  upward  on  the  afi^ected  side 
and  downward  on  the  other,  the  lumbar  spine  bending  with  the  con- 
vexity toward  the  lower  side  (Figs.  248  and  251).  If  the  level  of  the 
pelvis  be  restored,  the  adducted  limb  will  be  crossed  over  its  fellow 
and  the  deformity  is  made  evident  (Fig.  247). 


^llfe-X 

1 

■ 

2 

P 

W 

•"'^g'f 

'1  *  '^ 

^O 

^^^^^H^^^Hf 

^*™™!«W^g3W^^i^ 

Fig.  246. — The  degree  of  fixed  flexion  is  shown  when  the  lumbar  spine  is  held  in 
contact  with  the  table  by  flexing  the  other  thigh. 

As  has  been  stated,  the  attitude  of  flexion,  adduction,  and  inward 
rotation,  if  it  appears  early,  is  usually  an  indication  of  acute  disease 
and  of  corresponding  intensity  of  muscular  spasm.  But  in  most 
instances  it  is  associated  with  the  later  and  destructive  stage  of  the 
disease,  and  it  by  no  means  indicates  that  the  preceding  symptoms 
have  been  more  than  ordinarily  acute.  In  fact  it  is  the  attitude 
characteristic  of  a  so-called  "natural  cure"  (Fig.  249)  when  mechani- 
cal treatment  has  not  been  employed.  It  more  often  accompanies 
the  later  course  of  the  disease,  because  its  causes  are  in  great  degree 
mechanical. 

This  is  illustrated  by  Konig's  statistics  of  499  cases  of  hip  disease. 

In  267  cases  the  limb  was  abducted,  and  in  31  per  cent,  of  these 
there  was  actual  shortening. 

In  232  cases  adduction  was  present,  and  in  70  per  cent,  the  limb 
was  shorter  than  its  fellow.^ 

1  Konig:  Das  Hoeftgelenk,  Berlin,  1902. 


316 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINf 


The  mechanics  of  the  distortion  as  indicative  of  the  destructive 
stage  of  the  disease  will  be  made  clearer  if  it  be  compared  to  the 
deformity  caused  by  dorsal  dislocation  of  the  hip.  In  this  displace- 
ment the  femur,  forced  upward  and  backward  upon  the  pelvis,  is 


jjJBBI^^    * 

m 

-                     ^3 

m 

B[iJa 

1 

t 

^ 

Fig.  247. — Apparent  shortening.  The 
adduction  of  the  right  thigh  is  made  evi- 
dent by  the  involuntary  crossing  of  the 
legs  when  the  anterior  superior  spines 
are  on  the  same  plane. 


Fig.  248. — Apparent  shortening. 
When  the  adducted  limb  is  placed  in 
the  line  of  the  body,  the  pelvis  is  tilted 
upward  on  the  adducted  side  and  down- 
ward on  the  other.  The  patient  has 
compensated  for  the  apparent  shorten- 
ing by  flexing  the  knee  on  the  sound 
side.  This  does  not  appear  in  the 
photograph. 


fixed  in  an  attitude  of  extreme  flexion,  adduction,  and  inward  rota- 
tion. Each  of  the  destructive  changes  of  hip  disease,  the  enlarge- 
ment of  the  acetabulum,  the  depression  of  the  neck  of  the  femur, 
and  the  erosion  of  the  head  of  the  bone,  is  accompanied  by  an  eleva- 


PHYSICAL  SIGNS 


317 


tion  of  the  femur  upon  the  pelvis  or  an  approximation  to  a  dorsal 
displacement  (Fig.  252).  If  this  displacement  occurs  suddenly,  as 
in  certain  cases  of  acute  disease  attended  by  effusion  and  rupture  of 
the  capsule,  the  limb  immediately  assumes  an  attitude  typical  of 


Fig.  249.— The  final  effect  of  hip  dis- 
ease when  untreated.  The  natural  cure, 
with  flexion  and  adduction.  Compensa- 
tory recurvation  of  the  knee  on  the  sound 
side  is  also  shown. 


Fig.  250. — Untreated  hip  disease. 
Flexion  deformity  to  nearly  a  right 
angle  with  the  body.  Trochanter  two 
inches  above  Nelaton's  line.  Com- 
pensatory lordosis. 


dorsal  dislocation;  but  in  the  ordinary  form  of  disease  the  changes 
are  very  gradual,  the  pelvis  and  the  femur,  being  in  most  instances 
undeveloped,  more  readily  accommodate  themselves  to  the  changed 
conditions,  so  that  the  actual  distortion  is  less  marked  than  in  a 
similar  subluxation  of  traumatic  origin  in  the  adult;  but  the  simile 


318 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


will  serve  to  illustrate  the  mechanical  causes  of  distortion,  and  why 
such  deformity  may  recur  after  correction,  even  though  the  disease 
has  entirely  disappeared.     Outward  rotation  of  the  limb  is  usually 

associated  with  abduction,  and  in- 
ward rotation  with  adduction,  but 
in  certam  instances  outward  rota- 
tion may  be  combmed  with  adduc- 
tion and  inward  rotation  with  ab- 
duction. These  irregular  attitudes 
are  more  often  observed  in  cases 
that  have  received  mechanical  or 
operative  treatment  than  in  those 
in  which  the  disease  has  pursued 
its  natural  course. 

As  has  been  stated,  the  distor- 
tions of  the  early  stageof  hip  disease 
are  caused  almiost  entirely  by  mus- 
cular contraction  which  relaxes 
under  the  mfluence  of  an  anes- 
thetic, but  after  a  time  the  attitude 
is  confirmed  by  accommodative 
changes  in  the  muscles  and  fasciae, 
and  by  contractions  and  adhesions 
about  the  capsule.  Thus  an  atti- 
tude originally  a  s^Tuptom  persists 
after  the  cure  of  the  disease. 

One  may  conclude  then  that 
flexion  is  practically  an  invariable 
s^•mptom  in  hip  disease  because 
complete  extension,  the  attitude 
that  puts  most  stram  upon  the 
joint,  is  first  restricted.  Flexion 
in  the  milder  or  in  the  earlier  class 
of  cases  is  usually  combined  with 
abduction  and  outward  rotation, 
the  attitude  of  inactivity.  In- 
creased flexion,  accompanied  by 
adduction  and  inward  rotation  is 
an  indication  of  a  more  acute  phase 
of  the  disease.  If  the  attitude  is 
retained  for  a  time  it  becomes 
fixed  by  accommodative  changes 
in  the  tissues;  thus  the  distortion 
is  not  unusual  in  cases  in  which 
the  damage  to  the  joint  may  be  very  slight,  as,  for  example,  when  it 
follows  some  form  of  infectious  arthritis.  But  in  most  instances 
the  attitude  is  indicative  of  more  advanced  disease  and  of  destruc- 
tive changes  within  the  joint. 


Fig.' 2.51. — Stage  of  apparent  short- 
ening. The  left  limb  is  adducted  35  °, 
making  an  apparent  shortening, 
measured  from  the  umbilicus,  of  more 
than  two  inches.  In  order  to  reduce 
the  obliquity  of  the  pehis,  the  ad- 
ducted leg  must  be  crossed  over  its 
fellow.  (See  Fig.  247.)  The  apparent 
shortening  is  compensated  by  the 
flexion  at  the  knee  on  the  sound  side. 
This  is  not  made  clear  in  the  photo- 
graph. 


PHYSICAL  SIGNS  319 

Changes  in  the  Contour  of  the  Hip. — The  changes  in  contour  are 
caused  primarily  by  the  attitude  of  the  limb.  If,  as  is  usual,  it  is 
flexed,  abducted,  and  rotated  outward,  the  buttock  appears  somewhat 
flatter  and  broader  than  its  fellow.  The  gluteofemoral  fold  is  lower 
because  of  the  tilting  downward  of  the  pelvis  and  it  is  shallower 
because  of  the  flexion.  If  the  thigh  is  adducted,  the  gluteal  fold  is 
elevated  and  shortened.  On  the  anterior  aspect  the  inguinofemoral 
fold  is  deepened  and  lengthened  by  flexion  and  adduction  while 
abduction  makes  it  less  noticeable.  Hoffman  has  called  attention  to 
the  fact  that  the  genitals  and  the  intergluteal  fold  point  toward  the 
abducted  and  away  from  the  abducted  thigh.  Adduction  makes 
the  trochanter  more  prominent,  and  abduction  makes  it  less 
prominent. 

To  these  primary  changes  in  the  appearances  must  be  added  the 
effect  of  atrophy  or  of  infiltration  and  swelling,  due  directly  to  the 
disease.  A  certain  amount  of  swelling  indicating  effusion  into  the 
joint  is  often  apparent  in  the  inguinofemoral  region,  and  infiltration 
of  the  deeper  tissues  is  sometimes  evident  on  palpation.  In  such 
cases  there  is  usually  a  certain  sensitiveness  to  deep  pressure  behind 
or  in  front  of  the  trochanter.  Palpable  abscess  is  unusual  in  the 
early  stage  of  the  disease. 

Atrophy. — Atrophy  is  -an  important  sign  of  joint  disease.  It  is 
often  appreciable  to  the  eye  and  to  the  hand,  and  it  is  always 
demonstrable  by  measurement.  It  is  an  important  symptom, 
because,  if  well-marked,  it  shows  that  the  disease  must  have  existed 
for  some  time,  whatever  may  be  the  statement  of  the  patient's 
relatives. 

The  atrophy  affects  the  muscles  of  the  entire  limb,  although  it 
is  somewhat  more  marked  in  the  muscles  of  the  thigh  than  in  the 
calf.  In  the  ordinary  case  of  hip  disease  in  childhood,  when  the 
patient  is  first  brought  for  treatment,  it  averages  from  one-half  to 
one  inch  in  the  thigh  and  somewhat  less  in  the  calf,  and,  as  has 
been  stated  elsewhere,  atrophy  of  muscles  is  accompanied  by  a  cor- 
responding atrophy  of  bone  as  well. 

The  Causes  of  Atrophy. — Admitting  that  the  secondary  causes 
of  atrophy  are  somewhat  obscure,  one  cause,  and  by  far  the  most 
important,  is  very  evident.  This  is  physiological  disuse,  and  thus 
diminished  nutrition  of  the  limb,  which  has  become  incompetent 
to  carry  out  its  full  function.  Atrophy  is  a  constant  symptom  of 
simple  disuse  in  the  absence  of  disease.  If  a  bone  has  been  broken, 
atrophy  of  the  muscles  is  observed.  If  anchylosis  of  a  joint  occurs 
from  any  cause,  whether  it  be  from  injury  or  disease,  atrophy  of  the 
muscles,  whose  function  has  been  abolished,  follows.  Even  the 
atrophy  caused  by  disease  of  the  hip-joint  is  greater  when  the  limb 
has  been  fixed  in  apparatus  than  when  none  has  been  applied, 
although  the  treatment  has  allayed  the  pain  and  has  checked  the 
progress  of  the  disease.    This  point  is  illustrated  by  the  observations 


320  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

of  Brackett/  who  contrasted  the  atrophy  of  hip  disease  in  two 
groups  of  patients,  in  one  of  which  motion  had  been  permitted, 
while  in  the  other  fixation,  as  complete  as  possible,  had  been  em- 
ployed. In  the  first  group  the  average  of  atrophy  was  but  1  per 
cent,  of  the  volume  of  the  thigh  and  0.89  per  cent,  of  that  of  the  leg, 
as  contrasted  with  23  per  cent,  and  17  per  cent,  in  the  second  class. 


Fig.  252. — Advanced  disease,  showing  wandering  of  the  acetabulum  and  the 
obliquity  of  the  pelvis  due  to  adduction.  Actual  shortening  one  inch,  apparent 
shortening  three  inches. 

According  to  the  investigations  of  Bum,-  simple  fixation  of  a 
sound  limb  induces  more  rapid  atrophy  than  is  caused  by  disease 
of  a  joint  when  function  has  been  permitted.  Nor  can  the  atrophy 
induced  by  simple  fixation  be  increased  by  the  induction  of  disease 
in  the  fixed  joint. ^ 

1  Tr.  Am.  Orthop.  Assn.,  iv. 

2  Ztschr.  f.  Chir.,  December  9,  1905. 

3  Wien.  med.  Presse,  1906,  li. 


PHYSICAL  SIGNS  321 

The  atrophy  caused  by  physiological  disuse  and  diminished  nutri- 
tion affects  all  the  components  of  the  limb.  The  skin  becomes 
thinner,  the  muscles  lose  in  volume,  the  contractile  substance  is 
replaced  in  part  by  fat  and  by  fibrous  tissue,  and  the  medullary 
canals  of  the  bones  enlarge  at  the  expense  of  the  cortical  substance. 

In  childhood  disuse  often  causes  a  retardation  in  growth  of  the 
entire  extremity.  This  may  be  apparent  in  the  foot  when  it  is 
placed  by  th©  side  of  its  fellow,  while  the  diminished  growth  in  the 
length  of  the  limb  may  be  demonstrated  by  measurement.   Brackett, 


Fig.  253. — Illustrating  the  destructive  type  of  hip  disease.     The  limb  having  been 
fixed  in  abduction.     No  displacement  is  present. 

in  a  series  of  cases,  found  this  shortening  to  be  distributed  as 
follows:  average  loss  of  the  femur  6.6  per  cent,  and  of  the  tibia  5.4 
per  cent,  of  the  normal  length. 

Atrophy  becomes  less  noticeable  after  function  is  resumed,  the 
degree  of  final  inequality  depending  upon  the  severity  of  the  disease, 
the  duration  of  the  treatment,  and  upon  the  impairment  of  function. 
But  even  when  free  motion  in  the  joint  is  retained,  a  certain  degree 
of  atrophy  always  persists  and  the  loss  in  growth  is  never  regained. 
If  motion  is  completely  lost  the  muscles  about  the  joint  lose  in  bulk 
in  proportion  to  the  disuse  of  their  normal  function;  whereas  the 
21 


\'^,'>. 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


bones  of  the  limb  which  are  still  used  to  support  the  weight  retain 
to  a  greater  degree  their  normal  size  and  length.  Contrasted  with 
this  atrophy  there  is  a  relative  hypertrophy  of  the  sound  limb, 
which  is  forced  to  assume  more  than  its  share  of  work. 

Actual  Shortening. — Actual  shortening  of  the  limb  is  an   effect 
rather  than  a  diagnostic  symptom  of  hip  disease. 


Fig.  254. — Dislocation  secondary  to  disease  of  the  hip-joint. 

The  causes  of  actual  shortening  may  be  classified  as : 

1.  Disuse  of  the  limb. 

2.  The  effect  of  the  disease  upon  the  epiphyseal  cartilage  of  the 
head  of  the  femur. 

3.  The  more  general  destructive  effects  of  the  disease  that  cause 
upward  displacement  of  the  femur. 

(a)  Erosion  of  the  head. 

(6)  Erosion  of  the  acetabulum. 

(c)  Depression  of  the  neck  of  the  femur. 

(d)  Dislocation. 

Disuse,  particularly  of  weight-bearing  throughout  a  long  period, 
causes  a  certain  amount  of  shortening  of  the  entire  limb.  To  this 
the  shortening  of  the  bones  of  the  leg  and  of  the  foot  may  be 
attributed  in  great  part.     If  the  epiphyseal  cartilage  uniting  the 


PHYSICAL  SIGNS 


323 


neck  and  the  head  of  the  femur  is  destroyed  in  whole  or  in  part  or 
if  the  disease  hastens  union  at  this  point,  a  certain  loss  of  growth 
must  follow.  This  is,  of  course,  slight  in  degree,  because  growth 
here  is  relatively  unimportant  compared  with  that  at  the  lower 
extremity  of  the  femur. 

Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of  the 
acetabulum  are  usually  combined  in  those  cases  in  which  the  short- 
ening is  in  part  dependent  on  upward  displacement  of  the  trochanter 
(Fig.  240).  Depression  of  the  neck  of  the  femur  is  usually  caused 
by  disease  of  its  substance  and  is  uncommon.  Elevation  of  the  tro- 
chanter, due  to  one  or  more  of  these  causes,  a  form  of  subluxation, 
is  very  common,  particularly  so  in  those  cases  in  which  the  pro- 
tective treatment  has  been  inefficient.  Greater  displacement 
follows  fracture  of  the  weakened  neck  and  complete  destruction  of 
the  head,  and  occasionally  a  fairly  normal  femur  may  be  actually 
dislocated  as  a  result  of  sudden  effusion  into  the  joint  with  rupture 
of  the  capsule — a  form  of  pathological  dislocation.     (Fig.  254.) 

It  may  be  stated  also  that  partial  or  complete  anterolateral  dis- 
placement is  not  uncommon.  In  such  cases  there  is  marked  out- 
ward rotation  of  the  limb  with  but  slight  shortening,  the  head  of  the 
bone  presenting  by  the  side  of  the  antero-inferior  spine  of  the  pelvis. 

Retardation  of  Growth. — As  has  been  stated,  all  the  components 
of  the  limb  are  affected  by  the  retardation  of  the  growth;  Brackett's 
observations  on  this  point  have  been  mentioned,  and  the  accompany- 
ing table  showing  the  relative  measures  of  the  bones  in  cases  under 
treatment  by  Dollinger,^  of  Budapest,  presents  the  subject  in  a 
convenient  form: 


Age  at 

Duration  of 

Length  of 

Leng 

th  of 

No.  of 

inception. 

disease. 

femur  in  cm. 

Differ- 
ence. 

tibia  in  cm. 

Differ- 

case. 

Years. 

Months. 

Years. 

Months 

Dis- 
eased. 

Nor- 
mal. 

Dis- 
eased. 

Nor- 
mal. 

ence. 

1 

8 

6 

6 

28i 

28 

+  i 

24.0 

24.0 

2 

3 

4 

8 

23 

24 

1 

19.0 

19.0 

3 

2 

10 

1 

8 

24 

24 

19.5 

19.5 

4 

5 

2 

29 

30 

1 

23.5 

23.5 

.5 

6 

2 

27 

28 

1 

23.0 

23.0 

6 

7 

2 

32 

33 

1 

27.0 

27.0 

7 

9 

2 

37 

37 

30.0 

30.0 

8 

1 

4 

22 

24 

2 

18.5 

19.0 

0.5 

9 

13 

4 

38 

41 

3 

34.0 

34.0 

10 

4 

6 

5 

32 

34 

2 

27.0 

27.0 

11 

2i 

6 

26 

27 

1 

21.5 

23.0 

1 

12 

13 

7 

38 

40 

2 

33.0 

33.0 

13 

2 

8 

35 

36 

1 

28.0 

28.0 

14 

6 

8 

38 

38 

31.0 

32.0 

15 

11 

8 

40 

44 

4 

34.0 

34.0 

16 

5 

10 

45 

46 

1 

17 

5 

11 

41 

44 

3 

31.0 

37.0 

6.0 

18 

6 

14 

44 

48 

4 

36.0 

39.5 

3.5 

19 

2 

18 

36 

46 

10 

38.0 

38.0 

20 

2 

28 

44i 

45 

1 

2 

37.5 

37.5 

1  Ztschr.  f.  orthop.  Chir.,  1892,  i. 


324 


TUBERCULOUS  DISEASE  OF   THE  HIP- JOINT 


H.  L.  Taylor  made  a  similar  investigation  of  33  cases  under  treat- 
ment at  the  Hospital  for  Ruptured  and  Crippled.  In  these  cases 
the  shortening  of  the  bones  was  found  to  be  more  generally  dis- 
tributed than  in  those  reported  by  Dollinger,  as  is  illustrated  by  the 
following  table: 


Shortening  in  inches. 


3-a  >) 


6 
13 


11 
9 


Left 

1 

Right 

1* 

Left 

2 

Right 

2 

Left 

2* 

Left 

3 

Right 

3 

Right 

3 

Left 

3^ 

Left 

3* 

Right 

3^ 

Right 

3^ 

Left 

3* 

3i 
31 
li 
3i 


No 

No 

No 

No 

Yes 

No 

No 

No 

No 

No 

Yes 

No 

No 


1  a 

^  s 

1 

li 

li 


Average 


2  — 


14  M. 

15  '   F. 


16 
17 
18 
19 
20 
21 
22 
23 


Aver 


F. 

F. 

F. 

F. 

F. 

M. 

F. 

M. 


age 


12 
11 
13 
12 
10 
14 
15 
9* 


Right 

Right 

Right 

Right 

Left 

Left 

Left 

Left 

Right 

Right 


No 
No 
Yes 

Yes 
No 
No 
No 
Yes 
No 
Yes 


1 

1 

Si 

2i 
2 

X 

S 

u 

2i 

li 


li 


11        — 


31 


24 
25 
26 
27 
28 
29 
30 
31 
32 
33 
Aver 


F. 
M. 
M. 
F. 
M. 
F. 
F. 
F. 
F. 
F. 
age 


13 

15 

lOi 

18 

18 

15 

15 

15 

16 

21 

15 


Right 

Right 

Right 

Right 

Right 

Left 

Right 

Right 

Left 

Left 


8 

7 

Yes 

2J 

1 
4 

9 

6 

Yes 

4i 

2 

9 

X 

No 

U 

i 

9 

7 

No 

21 

X 

11 

10 

Yes 

2 

i 

11 

7 

Yes 

3 

4 

11 

5 

Yes 

1 

1 

Hi 

9i 

Yes 

3 

3 

14 

1 

No 

li 

3 

4 

17 

6 

Yes 

5i 

2i 

11 

6 

— 

2f 

8 

—  IMeasurements  equal.  x  Measurements  not  taken. 

Measurements  of  the  femur  from  the  apex  of  the  great  trochanter  to  the  knee- 
joint.  Patella  measured  transversely.  The  cases  are  grouped  according  to  the 
duration  of  disease  and  the  averages  are  given  separately  for  each  group. 


HISTORY  AND  METHOD  OF  EXAMINATION  325 

Dr.  Taylor  measured  also  10  cases  of  unilateral  poliomyelitis, 
in  patients  of  an  average  age  of  thirteen  years,  with  an  average 
duration  of  disability  of  ten  years.  The  average  shortening  in  these 
cases  was  one  and  three-fourths  inches,  and  in  no  case  was  it  greater 
than  two  and  one-half  inches.  It  will  be  noted  that  the  retardation 
of  growth  in  this  group  corresponds  closely  with  that  of  the  third 
group  of  caSes  of  hip  disease,  in  which  the  disability  was  of  about  the 
same  duration.  Taylor  concludes  that  the  retardation  of  growth 
from  unilateral  hip  disease  in  childhood  is  dependent  in  great  degree 
upon  the  duration  of  the  disability  and  upon  the  corresponding 
restraint  of  function. 

Actual  Lengthening. — Lengthening  of  the  limb  as  the  result 
of  disease  is  occasionally  observed  during  the  active  stage  of  the 
disease,  caused,  it  may  be  inferred,  by  granulations  within  the 
acetabulum  that  press  the  femur  outward  and  downward.  Actual 
lengthening  of  the  femur  is  uncommon,  but  it  does  occur,  induced, 
it  may  be,  by  stimulation  of  the  growth  of  the  epiphysis  of  the  head ; 
but  the  most  extreme  instances  are  those  in  which  the  upper  portion 
of  the  shaft  of  the  femur  is  involved,  the  lengthening  being  the  effect 
of  an  irritative  hypertrophy.  This  is  more  commonly  the  result  of 
extra-articular  disease. 

General  Symptoms  of  the  Disease. — Debility. — If  the  disease  is 
sufficiently  painful  to  cause  loss  of  sleep  and  to  affect  the  appetite, 
pallor  and  loss  of  flesh  and  strength  may  be  expected.  It  must  be 
borne  in  mind,  however,  that  the  patient  may  have  been  in  poor 
condition  long  before  the  local  tuberculous  disease  was  acquired. 
At  all  events,  from  the  diagnostic  stand-point  at  least,  the  local  disease 
has  no  characteristic  influence  upon  the  general  condition,  and  the 
appearance  of  perfect  health  is  not  at  all  unusual  among  patients 
with  hip  disease. 

Fever. — It  is  probable  that  a  slight  elevation  of  temperature  might 
be  detected  in  a  large  proportion  of  the  patients,  and  in  such  cases 
actual  appreciable  fever  often  follows  overexertion  of  injury.  Fever, 
as  a  symptom  of  infected  abscess  in  the  later  course  of  the  disease, 
is,  of  course,  of  importance,  but  in  the  early  stages  of  the  disease  the 
record  of  the  temperature  would  be  of  but  little  diagnostic  value. 

History  and  Method  of  Examination. — In  considering  the  differ- 
ential diagnosis  of  tuberculous  disease  of  the  hip-joint  one  should 
keep  its  characteristics  in  mind.  It  is  a  chronic  disease,  in  that  the 
symptoms  have  usually  persisted  for  weeks  or  months  before  the 
patient  is  brought  for  treatment.  It  is  essentially  a  monarticular 
disease,  thus  differing  from  rheumatism  and  similar  affections  in 
which  several  joints  are  involved.  It  does  not  get  well;  thus  it  may 
be  differentiated  from  injury  and  from  the  minor  affections  that 
simulate  some  of  its  symptoms.  It  causes  a  limp.  It  is  accom- 
panied by  reflex  muscular  spasm,  usually  by  a  certain  degree  of 
deformity  and  by  general  atrophy  of  the  muscles  of  the  limb. 


326  TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 

The  importance  of  the  inheritance  and  of  the  personal  history 
of  the  patient  has  been  mentioned  aheady  in  the  consideration  of 
Pott's  disease.  In  recording  the  history  in  this  as  in  all  other 
chronic  diseases  of  childhood  one  attempts  to  ascertain  the  approxi- 
mate duration  of  the  pathological  process  rather  than  the  duration 
of  the  more  acute  symptoms  for  which  the  patient  has  been  brought 
for  treatment.  One  asks,  therefore,  when  the  child  was  last  per- 
fectly well,  and,  bearing  in  mind  the  remission  of  symptoms,  one 
asks  if  limp  or  pain  had  been  noticed  at  any  time  before  the  more 
acute  symptoms.  In  the  history  there  is  almost  invariably  mention 
of  a  fall,  and  one  must  ascertain  whether  the  fall  had  any  influence 
in  the  causation  of  the  symptoms,  remembering  that  the  weakness 
and  interference  with  function  due  to  joint  disease  more  often  cause 
falls  than  falls  cause  joint  disease. 

Physical  Examination. — One  begins  the  physical  examination  by 
the  observation  of  the  general  condition  of  the  patient,  and  notes 
the  attitudes  and  the  character  of  the  limp.  The  patient's  clothing 
is  then  entirely  removed,  that  one  may  observe  the  contour  of  the 
part  and  the  general  influence  of  the  affection  upon  the  mechanism 
of  the  body.  The  patient  is  then  placed  on  his  back  upon  a  table, 
with  the  limbs  parallel  to  one  another,  so  that  length  and  size  may  be 
compared.  If  the  pelvis  is  level  when  the  limbs  are  parallel,  there 
can  be  no  persistent  abduction  or  adduction,  for  when  the  two 
anterosuperior  spines  are  on  the  same  plane  such  distortion  is 
always  evident.  If  the  lumbar  spine  and  the  popliteal  surfaces  of 
the  knees  rest  on  the  table  simultaneously  it  shows,  too,  that  per- 
sistent flexion  is  absent.  One  next  tests  the  function  of  the  hip- 
joints,  always  beginning  with  the  sound  side  for  the  purpose  of 
comparison,  and  in  order  that  the  patient  may  become  accustomed 
to  the  manipulation  before  the  one  suspected  of  disease  is  tested. 
Disease  within  a  joint  is  accompanied  by  muscular  spasm  that 
limits  motion  in  every  direction,  thus  differing  from  other  affections 
outside  the  joint  that  may  limit  its  motion  in  one  or  more  but  not 
in  all  directions. 

One  compares  the  flexion,  abduction,  adduction,  and  rotation 
of  the  limbs  while  the  child  lies  upon  its  back;  it  is  then  turned  upon 
its  face  to  test  for  extension  by  holding  the  pelvis  flat  upon  the  table 
with  one  hand  while  the  thigh  is  gently  elevated  with  the  other 
(Fig.  16).  The  normal  range  of  extension  in  childhood  is  about 
20  degrees  backward  from  the  line  of  the  body,  and  limitation  of 
this  range  is  the  earliest  indication  of  the  deformity  of  hip  disease. 
It  may  precede  the  restriction  of  the  extremes  of  motion  in  other 
directions,  although  this  is  unusual,  and  if  this  motion  is  unrestricted 
d'sease  of  the  joint  may  be,  practically  speaking,  excluded.  The 
character  of  the  reflex  spasm  that  limits  motion  and  the  indica- 
tions of  discomfort  when  the  limit  has  been  reached  have  been 
described. 


HISTORY  AND  METHOD  OF  EXAMINATION  327 

Measurements. — The  measurements  of  the  hmbs  are  then  made. 
One  first  ascertains  the  actual  length  of  the  limbs  by  measuring  from 
the  anterosuperior  spines  of  the  pelvis  to  the  extremities  of  the 
internal  malleoli,  actual  shortening  being,  of  course,  absent  in  the 
early  stage  of  the  disease.  The  second  measurement  is  from  the 
umbilicus  to  show  the  amount  of  apparent  shortening  or  lengthening 
that  may  be  present  if  the  limb  is  distorted.  The  actual  length  of 
the  limbs,  as  measured  from  the  anterosuperior  spines,  is  but 
slightly  affected  by  tilting  of  the  pelvis,  but  as  the  umbilicus  is  in  the 
middle  line  of  the  body  above  the  pelvis  measurement  from  this 
point  simply  shows  the  actual  distance  to  the  malleoli.  Persistent 
adduction  causes  compensatory  obliquity  of  the  pelvis;  conse- 
cfuently  the  malleolus  on  the  affected  side  is  drawn  upward  or  nearer 
to  the  umbilicus,  while  the  other  is  carried  downward  to  a  corre- 
sponding distance  (Fig.  244) .  If,  then,  the  measurements  from  the 
umbilicus  to  the  malleoli  do  not  correspond  relatively  with  those 
fron^the  anterosuperior  spines,  when  the  limbs  are  parallel  and  in 
the  median  line,  it  shows  distortion;  adduction,  if  the  limb  is  rela- 
tively shorter,  abduction,  if  it  is  relatively  longer  than  is  shown  by 
the  measurement  from  the  anterosuperior  spine.  It  has  been 
stated  that  the  measurement  from  the  anterosuperior  spine  is 
not  greatly  changed  by  distortion.  It  is,  however,  shortened  by  ab- 
duction, and  it  is  correspondingly  lengthened  by  adduction.  This 
is  explained  as  follows:  When  the  limb  is  in  the  line  of  the  body 
the  trochanter  is  below  the  anterosuperior  spine  from  which  the 
measurement  is  made.  Abduction  of  the  limb  raises  the  trochanter 
toward  the  plane  of  the  anterosuperior  spine,  and  consequently 
lessens  the  distance  from  this  point  to  the  extremity  of  the  limb. 
Adduction,  on  the  contrary,  lowers  the  trochanter  and  increases  the 
distance  between  these  two  points.  Ordinarily  the  variation  from 
this  source  does  not  exceed  half  an  inch.  But  if  the  distortion  is 
considerable  the  error  must  be  corrected  by  placing  the  sound  limb 
in  the  same  attitude  in  which  its  fellow  is  fixed.  The  measurements 
will  then  be  relatively,  though  not  absolutely,  accurate.  Flexion  of 
one  thigh  causes  a  tilting  forward  of  the  pelvis  that  lessens  the  dis- 
tance between  the  anterosuperior  spine  and  the  malleolus  on  both 
sides,  although  not  to  an  equal  degree.  It  is  customary,  therefore, 
if  the  flexion  is  considerable,  to  raise  the  unaffected  limb  to  the  line 
of  its  fellow  in  making  the  comparative  measurements,  stating  in  the 
record  that  the  limbs  have  been  measured  at  the  angle  of  the  deform- 
ity and  are  therefore  shortened. 

In  this  connection  it  may  be  noted  that  a  slight  difference  in  the 
length  of  the  limbs  is  not  uncommon  (78  per  cent,  of  128  observa- 
tions), usually  in  favor  of  the  right  side,  the  variation  being  one- 
fourth  to  one-half  inch.^ 

1  Bristow:  Ann.  Surg.,  July,  1909. 


328 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


Method  of  Estimating  the  Degree  of  Distortion  of  the 
Limb. — As  has  been  stated,  when  the  pelvis  is  level,  distortion  of  the 
limb  is  apparent,  and  the  degree  of  distortion  can  be  measured  by 
the  goniometer  (Fig.  247);  but  it  may  be  more  easily  ascertained 
by  "Lovett's  table. "^  This  method  is  described  by  its  author  as 
follows : 


Table  for  Estimating  the  Degree  of  Lateral  Distortion. 

BETWEEN   AnTEROSUPERIOR    SpINES   IN    InCHES. 


Distance 


3 

3i 

4 

4i 

5 

51 

6 

ei 

7 

7i 

8 

81 

9 

94 

10 

11 

12 

13 

4 

5° 

4° 

4° 

3° 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

1° 

1° 

1° 

1"= 

1° 

03 

* 

10 

8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

^ 

3 

14 

12 

11 

10 

8 

8 

7 

7 

6 

6 

5 

5 

5 

4 

4 

4 

3 

3 

s  s 

1 

19 

17 

14 

13 

11 

10 

9 

9 

8 

7 

7 

7 

6 

6 

6 

5 

5 

4 

^  g 

li 

25 

21 

18 

16 

14 

13 

12 

11 

10 

9 

9 

8 

8 

7 

7 

7 

6 

6 

s  '^ 

H 

30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

11 

10 

10 

9 

9 

8 

7 

7 

^  o 

If 

36 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

11 

10 

10 

9 

8 

8 

2 

42 

35 

30 

26 

23 

21 

19 

18 

16 

15 

14 

14 

13 

12 

13 

10 

10 

9 

gg   1 

2i 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

11 

10 

2J 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

11 

2i 

38 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

3 

42 

35 

32 

29 

27 

25 

23 

22 

21 

19 

18 

18 

16 

14 

12 

3i 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15 

14 

Si 

40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17 

16 

Q 

Si 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18 

17 

^      4 

42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19 

18 

"To  measure  by  this  method  the  patient  is  made  to  lie  straight 
with  the  legs  parallel.  Real  shortening  is  measured  with  the  ordi- 
nary tape  measure,  and  apparent  shortening  is  obtained  in  the  same 
way.  It  may  be  repeated  that  real  or  bony  shortening  is  measured 
from  the  anterosuperior  iliac  spines  to  each  malleolus,  and  that 
practical  shortening  is  found  by  a  measurement  taken  from  the 
umbilicus  to  each  malleolus.  The  difference  in  inches  between  the 
two  kinds  of  shortening  is  seen  at  a  glance.  The  only  additional 
measurement  necessary  is  the  distance  between  the  anterosuperior 
spines,  which  is  taken  with  the  tape.  Turning  now  to  the  table:  if 
the  line  which  represents  the  amount  of  difference  in  inches  between 
the  real  and  apparent  shortening  is  followed  until  it  intersects  the 
line  which  represents  the  pelvic  breadth,  the  angle  of  deformity  will 
be  found  in  degrees  where  they  meet.  If  the  practical  shortening  is 
greater  than  the  real  shortening,  the  diseased  leg  is  adducted;  if  less  than 
real  shortening,  it  is  abducted.  Take  an  example:  Length  (from 
anterosuperior  spine)  of  right  leg,  23;  left  leg,  22|;  length  (from 
umbilicus)  of  right  leg,  25;  left  leg,  23;  real  shortening,  |  inch; 
apparent  shortening,  2  inches;  difference  between  real  and  practical 
shortening,  1|  inches;  pelvic  measurement,  7  inches.  If  we  follow 
the  line  for  H  inches  until  it  intersects  the  line  for  pelvic  breadth  of  7 


1  R.  W.  Lovett:  Boston  Med.  and  Surg.  Jour.,  March  8,  1888. 


HISTORY  AND  METHOD  OF  EXAMINATION 


329 


inches,  we  find  12  degrees  to  be  the  angular  deformity ;  as  the  practical 
shortening  is  greater  than  the  real,  it  is  12  degrees  of  adduction  of 
the  left  leg.  If  apparent  lengthening  is  present  its  amount  should 
be  added  to  the  amount  of  actual  shortening." 

If  flexion  is  present  the  degree  may  be  ascertained  by  raising  the 
flexed  limb  until  the  lumbar  spine  touches  the  table,  when  the  angle 
formed  by  the  thigh  with  the  body  may  be  measured  with  the  goni- 
ometer (Fig.  246)  or  its  degree  may  be  ascertained  by  Ivingsley's 
table. 

"The  patient  lies  upon  a  table  flat  on  his  back  and  the  surgeon 
flexes  the  diseased  leg,  raising  it  by  the  foot  until  the  lumbar  verte- 
brae touch  the  table,  showing  that  the  pelvis  is  in  the  correct  position. 
The  leg  is  then  held  for  a  minute  at  that  angle,  the  knee  being 
extended,  while  the  surgeon  measures  off  2  feet  on  the  outside  of  the 
leg  with  a  tape  measure,  one  end  of  which  is  held  on  the  table,  so 
that  the  tape  measure  follows  the  line  of  the  leg  {A-B).  From  this 
point  on  the  leg  (B)  where  the  2  feet  reach  by  the  tape  measure,  one 


Fig.  255. — Kingsley's  method  of  estimating  flexion. 

measures  perpendicularly  to  the  table  (B-C),  and  the  number  of 
inches  in  the  line  B-C  can  be  read  as  degrees  of  flexion  of  the  thigh 
by  consulting  the  Table.  For  instance,  if  the  distance  between  the 
point  on  the  leg  and  the  table  is  12|  inches  it  represents  31  degrees 
of  flexion  deformity  of  the  thigh. 


Table  For 

Estimating 

THE  Degree  of 

Flexion. 

(Kingsley.) 

1 

0 . 5  inclies. 

1° 

6.5 

inches 

16°            12.5  inches. 

31° 

18.5  inches.    50 

1.0       ' 

2 

7.0 

17              13.0 

33 

19.0       ' 

52 

1.5       ' 

3 

7.5 

19              13.5 

34 

19.5       ' 

54 

2.0       ' 

4 

8.0 

20              14.0 

36 

20.0       ' 

56 

2.5       ' 

6 

8.5 

21              14.5 

37 

20.5 

58 

3.0       ' 

7 

9.0 

22              15.0 

39 

21.0 

60 

3.5       ' 

9 

9.5 

24              15.5 

40 

21.5 

63 

4.0       ' 

10 

10.0 

25              16.0 

42 

22.0       ' 

67 

4.5       ' 

11 

10.5 

27              16.5 

43 

22.5 

70 

5.0       ' 

12 

11.0 

28              17.0 

45 

23.0       ' 

75 

5.5       ' 

14 

11.5 

29              17.5 

47 

23.5 

80 

6.0       ' 

15 

12.0 

30              18.0 

48 

24.0 

90 

1  G.  L.  Kingsley:    Boston  Med.  and  Surg.  Jour.,  July  5,  1888. 


330  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

"  If  the  leg  is  so  short  it  is  impracticable  to  measure  off  24  inches, 
one  can  measure  12  inches;  ascertain  from  here  the  distance  to  the 
surface  on  which  the  patient  is  lying  in  a  perpendicular  line  in  the 
same  way,  then  doubling  this  distance  and  looking  in  the  Table  as 
before  the  amount  of  flexion  is  found." 

Atrophy. — The  circumference  of  the  thighs,  the  knees,  and  the 
calves  is  then  measured  at  corresponding  points  to  test  for  atrophy 
or  for  other  irregularities  that  may  require  explanation.  The 
atrophy  of  joint  disease  aft'ects  the  entire  limb,  and  it  is  an  unfailing 
symptom  except  in  the  earliest  stage  of  the  disease.  It  might  be 
concealed  in  the  thigh  by  a  deep  abscess,  but  it  would  still  appear 
in  the  calf. 

Local  Signs  of  Disease. — The  hip-joint  is  so  concealed  by  the 
overlying  tissues  that  the  local  sensitiveness  and  swelling  which 
usually  accompany  similar  disease  at  the  knee  and  ankle  are  often 
absent.  Firm  pressure  before  or  behmd  the  trochanter,  or  over  the 
head  of  the  femur  usually  causes  some  discomfort,  however.  In 
many  instances  a  peculiar  resistance  of  the  deeper  parts,  caused  by 
infiltration  of  the  tissues  that  cover  the  joint,  is  evident  on  palpa- 
tion; and  swelling  about  the  joint  and  thigh,  caused  by  effusion  or 
by  deep  abscess,  is  not  unusual  when  patients  are  first  brought  for 
treatment.  Sensitiveness  of  the  skin  and  local  elevation  of  the  tem- 
perature may  be  present  if  the  disease  is  acute,  particularly  if  an 
abscess  is  on  the  point  of  breaking  through  the  skin. 

Diagnosis. — The  diagnosis  of  tuberculous  disease  of  the  hip, 
except,  perhaps,  in  the  stage  of  inception  is  not  difficult,  and  errors 
are  due  rather  to  neglect  of  a  systematic  examination  than  to  any 
particular  obscurity  that  the  ordinary  case  may  offer. 

Local  Irritation. — Strains  of  the  muscles  of  the  thigh,  enlarged 
glands  in  the  groin,  irritation  or  disease  of  the  genitals  may,  in 
infancy  or  early  childhood,  cause  persistent  flexion  of  the  thigh  and 
pain  on  attempted  correction.  Simple  muscular  strains  quickly 
recover,  while  the  inflamed  glands  and  other  causes  of  local  irrita- 
tion are  usually  apparent  on  inspection. 

"Growing  Pains." — So-called  growing  pain  is  probably  due  in 
many  instances  to  strain  of  the  muscles  or  to  injury  about  the 
hip. 

Local  Injury. — It  would  appear  that  injury,  often  of  a  trivial 
character,  may  cause  congestion  in  the  neighborhood  of  the  epi- 
physeal cartilage  of  the  head  of  the  femur  and  that  injury  of  this 
character  in  delicate  children  may  be  a  predisposing  cause  of 
tuberculous  disease.  Such  a  sensitive  condition  causes  a  limp, 
pain,  or  discomfort  on  overuse  and  restriction  of  motion.  These 
symptoms  may  last  a  few  days  or  a  few  weeks;  they  may  disappear 
and  recur  from  time  to  time,  and  they  can  only  be  distinguished 
from  those  of  incipient  disease  by  continued  observation.  (See 
also  Fracture  of  the  Neck  of  the  Femur.) 


DIAGNOSIS  331 

Perthes'  Disease. — ^This  resembles  mild  hip  disease  so  closely  that 
the  diagnosis  can  be  made  only  on  .r-ray  examination.  It  is 
described  elsewhere. 

Synovitis. — In  certain  cases  of  injury  synovial  effusion  may  be 
present,  although  this  is  unusual. 

In  the  cases  in  which  the  functional  disturbance  is  caused  by  local 
irritation  x>r  by  slight  strain  the  symptoms  are  of  sudden  onset  and 
are  evidently  of  trivial  importance,  but  if  there  is  any  doubt  as  to  the 
diagnosis  the  hip  should  be  bandaged  and  the  patient  should  remain 
in  bed  or  at  rest  until  the  complete  subsidence  of  the  symptoms  or 
their  persistence  makes  the  diagnosis  clear. 

Anterior  Poliomyelitis. — Occasionally  anterior  poliomyelitis  may 
be  accompanied  by  pain  on  motion  in  the  affected  limb  before 
paralysis  is  apparent,  but  in  a  few  days  at  most  the  diagnosis  is 
evident. 

Rheumatism. — "Rheumatism,"  a  term  popularly  used  to  include 
all  forms  of  subacute  arthritis  induced  by  infection,  or  by  defective 
metabolism — "toxic  arthritis"  is  usually  of  sudden  onset.  It  is 
almost  always  migratory  in  character  and  it  is  accompanied  by 
fever.  If  it  were  confined  to  a  single  joint,  as  is  sometimes  the  case 
in  young  children,  and  if  the  history  were  obscure,  the  diagnosis 
might  be  uncertain  for  a  time.  In  such  cases  appropriate  remedies 
should  be  employed  with  the  local  treatment. 

Scurvy. — This  is  also  an  affection  whose  symptoms  are  general 
in  character.  It  is  therefore  more  likely  to  be  confounded  with 
rheumatism  than  with  a  local  disease.  In  rare  instances  one  joint 
only  appears  to  be  involved,  but  this  is,  as  a  rule,  the  knee  rather 
than  the  hip.  Pain  on  motion  of  the  limbs,  in  an  infant  artificially 
fed,  always  suggests  scurvy. 

Infectious  Arthritis  and  Epiphysitis. — Mild  forms  of  infectious 
arthritis  may  follow  scarlatina,  diphtheria,  pneumonia,  and,  in  a 
more  severe  and  destructive  form,  typhoid  fever.  As  a  rule,  however, 
several  joints  are  involved,  and,  although  the  affection  might  be 
mistaken  for  rheumatism,  it  could  hardly  be  confounded  with  local 
tuberculous  disease. 

Infectious  arthritis  or  epiphysitis  of  the  hip-joint  is  not  uncommon 
in  early  infancy.  It  is  of  sudden  onset,  accompanied  by  high  fever 
and  by  constitutional  disturbance.  These  symptoms,  together 
with  the  local  heat  and  swelling,  caused  by  the  rapid  formation  of 
pus,  show  the  character  of  the  affection  and  indicate  the  necessity 
for  prompt  surgical  intervention. 

Gonorrheal  arthritis  is  a  form  of  joint  infection  that  in  adult  age 
may  resemble  somewhat  the  subacute  form  of  tuberculous  disease. 
As  a  rule,  however,  it  is  of  sudden  onset  and  is  evidently  associated 
with  the  local  disease. 

Extra-articular  Disease. — Disease  in  the  neighborhood  of  the  joint, 
as  of  the  trochanter  or  of  the  tuberosity  of  the  ischium,  may  cause  a 


332  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

limp  and  pain;  in  most  instances  the  local  sensitiveness  and  local 
swelling  indicate  the  seat  of  the  disease,  while  motion  of  the  joint  is 
limited  only  in  the  directions  that  cause  tension  on  the  sensitive 
parts. 

Arthritis  Deformans  of  the  Hip. — This  affection  when  confined  to 
the  hip-joint  may  be  mistaken  for  tuberculous  disease,  and  at  times 
the  diagnosis  may  be  obscure.  It  is,  however,  essentially  a  disease 
of  adult  life,  and  it  is  in  most  instances  accompanied  by  other  evi- 
dences of  a  general  disease. 

Proliferative  Polyarthritis. — ^This  aft'ection  in  childliood  may  begin 
in  a  single  joint.  The  pain  may  be  severe,  and  there  may  be  spasm 
and  distortion  of  the  limb.  The  diagnosis  is  usually  made  clear  by 
the  successive  involvement  of  other  joints. 

Pott's  Disease. — Disease  of  the  lumbar  region  of  the  spine  before 
the  stage  of  deformity,  when  the  pain  is  referred  to  the  lower  extremi- 
ties, and  in  which  unilateral  psoas  contraction  causes  a  limp,  is  often 
mistaken  for  hip  disease,  although  the  distinction  between  them  is 
very  clear.  Psoas  contraction  limits  extension  only;  all  the  other 
movements  of  the  limb  are  unrestrained.  The  muscular  spasm,  of 
which  the  psoas  contraction  is  a  part,  is  a  spasm  of  the  muscles  of 
the  spine  about  the  seat  of  disease,  as  is  evident  on  examination. 
Other  causes  of  psoas  contraction  have  been  mentioned  in  the  con- 
sideration of  Pott's  disease.  In  exceptional  cases  active  disease  of 
the  lower  region  of  the  spine  in  young  children  may  set  up  spasm  of 
the  muscles  about  the  hip,  and  rice  verfici,  so  that  it  may  be  impossible 
to  decide  at  the  first  examination  whether  the  irritation  is  m  the  hip 
or  in  the  spine  or  in  both. 

Sacro-iliac  Disease. — Disease  of  the  sacro-iliac  junction  is  very 
uncommon  in  childhood.  The  symptoms  and  the  attitude  resemble 
sciatica  rather  than  hip  disease.  There  is  local  pain  at  the  seat  of 
disease  upon  lateral  pressure  on  the  pelvis,  and  if  the  pelvis  be  fixed 
the  motion  at  the  hip-joint  will  be  found  to  be  practically  free  and 
painless. 

Pelvic  Disease. — Localized  disease  of  one  of  the  pelvic  bones  may 
cause  discomfort  and  a  limp.  The  cause  of  the  symptoms  is  usually 
explained  by  the  appearance  of  an  abscess. 

Disease  of  the  Bursse  About  the  Joint. — ^Inflammation  of  the  bursse 
about  the  hip  may  cause  local  swelling  and  sensitiveness,  a  limp  and 
limitation  of  motion  in  certain  directions,  but  the  characteristic 
muscular  spasm  of  hip  disease  is  absent.  Iliopsoas  bursitis  forms  a 
fluctuating  swehing  in  Scarpa's  space,  gluteal  bursitis  a  localized 
swelling  of  th(5  buttock. 

Coxa  Vara. — Depression  of  the  neck  of  the  femur  is  a  simple 
deformity.  It  causes  a  limp  and  more  or  less  discomfort,  but  the 
character  of  the  deformity,  shown  by  the  actual  shortening  and  by 
the  elevation  and  prominence  of  the  trochanter,  distinguishes  it 
from  hip  disease,  in  which  these  are  late  symptoms.     In  coxa  vara 


METHOD  OF  RECORDING  A  CASE  333 

there  is  unequal  limitation  of  motion,  abduction,  flexion,  and  inward 
rotation  being  somewhat  restricted,  while  extension  and  adduction, 
the  first  movements  limited  in  hip  disease  are,  as  a  rule,  not. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood  or  Traumatic  Coxa 
Vara. — Fracture  of  the  neck  of  the  femur  in  childhood  is  often  of 
what  may  be  termed  the  green-stick  variety,  a  depression  of  the 
neck  of  the  femur  without  actual  separation  of  the  fragments;  and 
in  many  instances  the  patients  are  able  to  walk  about  within  a  short 
time  after  the  accident.  In  such  cases  the  limp  and  discomfort, 
attended  during  the  stage  of  repair  by  a  certain  degree  of  muscular 
spasm,  are  often  mistaken  for  the  symptoms  of  disease.  The  his- 
tory of  the  accident  followed  by  immediate  disability,  the  short- 
ening and  the  elevation  of  the  trochanter  are  usually  sufficient  to 
exclude  disease.  In  doubtful  cases  the  .r-rays  may  be  required  to 
establish  the  diagnosis. 

Epiphyseal  Fracture. — Epiphyseal  fracture  is  more  common  in 
adolescence.  If  may  be  induced  by  slight  injury,  and  if  the  displace- 
ment is  not  complete  the  patient  is  often  able  to  use  the  limb.  A 
more  detailed  description  of  injuries  of  this  class  may  be  found 
elsewhere. 

Congenital  Dislocation  of  the  Hip. — Congenital  dislocation  of  the 
hip  causes  a  limp,  but  it  is  a  limp  that  has  existed  since  the  child 
began  to  walk  and  that  is  unaccompanied  by  the  symptoms  of  dis- 
ease.   The  nature  of  the  disability  should  be  apparent  on  examination. 

Hysterical  Joint. — In  hysterical  subjects  a  limp,  apparent  pain, 
and  distortion  of  the  limb,  often  following  slight  injury,  may  simu- 
late disease.  Hysteria  is  very  uncommon  at  the  period  of  life  in 
which  tuberculous  disease  is  most  frequent.  Patients  of  this  class 
usually  present  other  symptoms  of  hysteria;  the  characteristic 
signs  of  disease,  muscular  spasm  and  atrophy,  are  absent,  while  the 
apparent  discomfort  and  the  voluntary  distortion  are  quite  out  of 
proportion  to  the  physical  evidences  of  injury  or  disease. 

The  X-rays  in  Diagnosis. — Roentgen  pictures  are  of  far  more  value 
in  demonstrating  deformity  than  in  establishing  early  diagnosis  of 
disease,  especially  of  the  hip  in  early  childhood,  when  so  large  a  part 
of  the  extremity  of  the  femur  is  cartilaginous;  the  only  constant 
indications  of  disease  being  atrophy  of  the  shaft  of  the  femur  and  a 
blurred  outline,  "fogginess,"  of  the  parts  actually  involved.  The 
pictures  are  of  value,  however,  in  showing  the  destructive  effect  of 
the  disease  on  the  head  of  the  femur  or  acetabulum,  and  thus  giving 
one  a  clearer  conception  of  the  actual  condition  of  the  joint  than 
would  be  possible  otherwise  (Fig.  253).  In  older  subjects  it  may 
be  possible  to  demonstrate  the  presence  of  disease  in  the  interior  of 
the  bone  by  this  means,  but  in  any  event  Roentgen  pictures  are  of 
value  only  when  interpreted  by  knowledge  of  the  physical  signs. 

Method  of  Recording  a  Case. — The  record  should  contain  the 
general  history  of  the  patient  together  with  an  account  of  the  more 


334  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

important  s\7nptoms,  and  of  the  treatment  that  may  have  been 
employed.  The  physical  examination  should  include  the  weight 
and  height  for  comparison  with  the  normal  standard,  and  as  a  basis 
on  which  to  judge  the  future  progress  of  the  case.  Then  follows  a 
brief  description  of  the  gait  and  attitude,  of  the  character  of  the  dis- 
tortion, if  it  be  present,  and  of  the  changes  from  the  normal  con- 
tour. If  restriction  of  motion  is  present,  its  causes  are  stated  if 
possible;  whether,  for  example,  it  is  due  to  simple  muscular  spasm 
or  in  part  to  adhesions  and  contractions. 

The  presence  or  absence  of  heat  and  swelling,  of  abscesses,  sinuses, 
and  the  like  is  indicated.  If  there  is  actual  shortening  of  the  limb 
its  causes  and  distribution  should  be  stated ;  whether  it  is  the  result 
of  simple  retardation  of  gro^^th  or  of  elevation  of  the  trochanter, 
as  may  be  ascertained  by  Xelaton's  line  and  by  Bryant's  triangle. 

If  the  elevation  is  due  in  great  part  to  the  enlargement  of  the 
acetabulum,  while  the  upper  extremity  of  the  femiu*  remains  fairly 
normal  in  shape,  the  projection  of  the  trochanter  is  more  noticeable, 
and  the  distortion  of  the  limb  in  adduction  is  greater,  than  when  the 
elevation  is  the  result  of  destruction  of  the  head  of  the  bone.  In  this 
class  of  cases  Roentgen  pictiues  are  of  service  in  showing  the  actual 
condition  of  the  joint  (Fig.  252). 

A  condensed  account  of  the  more  important  points  in  the  physical 
examination  may  be  presented  by  the  formula  used  at  the  Hospital 
for  Ruptured  and  Crippled,  as  follows:  R.A. — R.U. — R.T. — R.K, 
— R.C.— A.G.E.— A.G.F.— A.S.P.— L.A.— L.U.— L.T.— L.K.— L.C. 

"A"  indicates  the  distance  from  the  anterosuperior  spines  to 
the  internal  malleoli. 

"U,"  from  the  lunbilicus  to  the  same  points. 

''T,"  "K,"  and  "C,"  the  chcumferences  of  the  limb  at  the  thighs, 
knees,  and  calves. 

"  A.G.E."  indicates  the  angle  of  greatest  extension. 

"A.G.F.,"  the  angle  of  greatest  flexion.  Thus  the  restriction  of 
the  range  of  anteroposterior  motion  at  the  hip  is  shown  by  these 
measiuements. 

"A.S.P."  is  the  transverse  diameter  of  the  pelvis  between  the 
anterosuperior  spines,  the  measiuement  required  in  Lovett's  table 
for  ascertaining  the  degree  of  lateral  distortion. 

If,  for  example,  the  record  reads: 

R.A.  18*— R.U.  20  —R.T.  11  —R.K.  8J— R.C.  7i— A.G.E.  150— A.S.P.  7 
L.A.  18J— L.U.  21i— L.T.  lOi— L.K.  SJ— L.C.  TJ— A.G.F.     90 

It  would  show  at  a  glance  that  there  was  no  real  shortening,  that 
the  limb  was  abducted  because  of  the  one  and  a  quarter  inches  of 
apparent  lengthening,  according  to  the  table,  the  equivalent  of  10 
degrees  of  abduction.  It  would  show  that  there  was  permanent 
flexion  of  30  degrees  and  a  range  of  motion  between  the  limits  of 
flexion  and  extension  of  60  degrees,  as  compared  with  the  normal  of 
about  130  degrees. 


METHOD  OF  RECORDING  A   CASE 


335 


The  following  details  of  the  1000  cases  of  hip  disease  investigated 
for  me  by  Ashley  are  of  interest  as  illustrating  the  character  of  the 
cases  treated  at  the  Hospital  for  Ruptured  and  Crippled: 


The  Duration  of  Disease  when  Treatment  was  Begun. 


Three  months  or  less 
Three  to  six  months 
One  year  4  . 
Two  years  . 
Three  years 


396 

170 

124 

75 

29 


Four  years  .... 
Five  years   .... 
From  five  to  ten  years 
From  ten  to  forty  years 
Not  stated  .... 


21 
17 
35 
16 
37 

920 


The  Degree  of  Deformity  Present  on  First  Examination. 


No  deformity  . 
5  degrees  of  flexion 
10  degrees  of  flexion 
15  degrees  of  flexion 
20  degrees  of  flexion 
25  degrees  of  flexion 
30  degrees  of  flexion 
35  degrees  of  flexion 
40  degrees  of  flexion 
45  degrees  of  flexion 
50  degrees  of  flexion 


130 
44 
89 
69 

118 
32 

135 
56 
70 
41 
68 


55  degrees  of  flexion 
60  degrees  of  flexion 
65  degrees  of  flexion 
70  degrees  of  flexion 
75  degrees  of  flexion 
80  degrees  of  flexion 
85  degrees  of  flexion 
90  degrees  of  flexion 
More  than  90  . 
Not  stated  . 


10 
26 

8 
22 

2 
11 

1 
12 

1 
55 

1000 


Restriction  of  Motion  at  First  Examination. 
Normal  motion 


30 

A  range  of  motion  through  105  degrees 14 


90  degrees 65 

75  degrees 49 

60  degrees 95 

45  degrees 67 

30  degrees 112 

15  degrees 95 

5  degrees 157 

No  motion 147 

Not  stated 169 


A  range  of  motion  through 
A  range  of  motion  through 
A  range  of  motion  through 
A  range  of  motion  through 
A  range  of  motion  through 
A  range  of  motion  through 
A  range  of  motion  through 


Attitude  of  the  Limb  at  First  Examination. 

Flexion  to  a  greater  or  less  degree 

No  flexion 

Not  stated 


1000 

814 

130 

56 


1000 
Other  Distortions  Recorded. 

Abduction 254 

Adduction ......;..  167 

External  rotation 166 

Internal  rotation 58 

Actual  Shortening  when  Treatment  was  Begun. 


i  inch 129 

i  inch 143 


5 

.      .      ...  5 

2 

2 

.....  2 

2 

1 

416 

Shortening  absent  or  not  stated  in 584 

Abscess  not  present  in 105 


f  inch  . 

1  inch  . 
Ij  inches 
I5  inches 
If  inches 

2  inches 


22 
51 

9 
16 

6 
21 


2i  inches 
21  inches 

2  J  inches 

3  inches 
3i  inches 
3 1  inches 
9i  inches 


336  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

Treatment. — The  principles  that  should  govern  the  treatment 
of  a  disease  are  best  indicated  by  the  study  of  cases  that  have 
received  no  treatment,  and  that  present,  therefore,  the  natural 
history  of  the  affection. 

A  characteristic  case  of  tuberculous  disease  of  the  hip-joint  begins 
insidiously.  It  causes  a  slight  limp  and  at  times  discomfort  and 
pain.  At  first  there  is  slight  flexion  of  the  limb,  usually  combined 
with  abduction,  the  instinctive  assumption  of  the  attitude  of  rest. 
As  the  disease  progresses  the  limb  becomes  less  capable  of  perform- 
ing its  proper  function;  the  range  of  motion  becomes  more  and  more 
restricted,  and  the  attitude  changes  to  one  of  increased  flexion  and 
adduction,  the  attitude  in  ■u'hich  the  limb  is  best  protected  from 
injiu-y  because  it  is  least  capable  of  function.  Pain  is  more  con- 
stant, abscess  is  often  present,  and  the  constitutional  effects  of  a 
depressing  disease  may  be  apparent.  This  progression  of  s^TQp- 
toms  and  attitudes  is  so  fairly  constant  that  hip  disease  was  formerly 
di^"ided  into  stages  corresponding  to  these  early  and  later  manifes- 
tations of  its  effects.  AMien  the  limb  has  reached  the  position  of 
greatest  protection,  when  motion  which  at  first  was  limited  only  by 
the  involuntary  spasm  of  the  muscles  that  are  now  atrophied,  is 
restricted  by  adhesions  and  contractions,  pain  often  ceases,  the  gen- 
eral health  improves,  and  effective  repair  begins.  Diuing  the  pro- 
gressive stage  erosion  of  the  opposing  siu*fac.es  of  the  joint  has 
advanced,  always  more  rapidly  at  the  points  of  mutual  pressure  and 
friction,  the  upper  and  inner  sm-face  of  the  head  of  the  femur  and 
the  upper  margin  of  the  acetabulum,  and  here  the  disease  remains 
active  while  repair  progresses  at  the  points  which  have  been  relieved 
from  irritation.  Thus  in  many  instances  the  upper,  margin  of  the 
acetabulum  is  destroyed  and  a  subluxation  of  the  femiu  takes  place 
(Fig.  241).  a  displacement  favored  by  the  attitude  of  flexion  and 
adduction,  and  induced  by  muscular  spasm  and  by  pressure  upon 
the  limb.  In  some  instances  there  is  complete  displacement,  and 
when  the  diseased  parts  are  thus  separated  from  one  another  by  this 
form  of  pathological  dislocation  relief  of  s^Tuptoms  and  practical 
recovery  may  quickly  follow,  although  sinuses  leading  to  areas  of 
local  disease  or  to  fragments  of  necrosed  bone  may  persist  for  many 
years. 

Nature's  cure  of  hip  disease  implies  recovery  with  a  shortened 
and  distorted  limb,  a  final  result  which  is  common  enough  even  when 
treatment  has  been  employed  to  explain  the  popular  conception  of 
what  hip  disease  entails  (Fig.  252). 

As  has  been  stated,  it  was  customary  in  former  years,  when  treat- 
ment was  neglected  or  was  less  efficient  than  at  the  present  time, 
to  speak  of  a  first,  second,  and  third  stage  of  hip  disease,  corre- 
sponding to  the  character  of  the  deformity,  but  early  or  later  stage 
as  used  by  the  writer  refers  to  the  inception  and  progression  of  the 
local  pathological  process,  not  to  the  distortion  of  the  limb. 


TREATMENT  337 

There  are  cases  of  hip  disease  in  which  the  primary  focus  in  the 
head  of  the  bone  is  so  hmited  in  extent  that  perfect  functional  cure 
may  result  under  any  form  of  treatment,  or  non-treatment  even. 
And  there  are  others  in  which  the  disease  is  of  such  a  destructive 
character  that  the  result  must  be  disastrous  in  spite  of  treatment. 
But  there  can  be  no  doubt  that  by  early  diagnosis  and  by  efficient 
protection»prolonged  suffering  may  be  prevented,  that  useful  func- 
tion may  be  preserved,  which  would  otherwise  have  been  lost. 

The  object  of  treatment  is  to  prevent  the  symptoms  and  the  effects 
of  the  disease  that  have  been  outlined  as  characteristic  of  the 
untreated  cases.  To  relieve  the  pain  that  depresses  the  vitality  of 
the  patient.  To  relieve  the  muscular  spasm  that  induces  distortion 
of  the  limb,  and  that  stimulates  the  activity  of  the  destructive  pro- 
cess by  increasing  the  pressure  and  friction  of  the  diseased  surfaces 
of  the  opposing  bones.  To  correct  and  to  prevent  deformity  and  to 
prevent,  as  far  as  may  be  by  lessening  the  pressure  and  by  restrain- 
ing motion,  the  upward  displacement  of  the  femur  that  causes 
irremediable  distortion. 

There  are  cases  in  which  radical  removal  of  the  diseased  parts 
may  be  indicated,  and  there  are  times  when  acute  symptoms  may 
require  absolute  rest  of  the  patient.  But  in  the  management  of  a 
chronic  tuberculous  disease,  throughout  the  period  of  years  that 
must  elapse  before  cure  is  accomplished,  the  primary  requirements 
of  the  treatment  that  have  been  indicated  must  be  met,  as  far  as 
may  be,  by  appliances  that  permit  exercise  in  the  open  air. 

Mechanical  Treatment. — Effective  treatment  of  a  diseased  joint 
must  assure  adequate  rest  and  protection.  If  the  disease  is  in  the 
earliest  stage  and  confined  to  the  interior  of  the  bone,  rest  offers  the 
most  favorable  condition  for  repair  and  for  preservation  of  the  joint. 
If  the  disease  is  further  advanced,  it  affords  an  opportunity  for 
Nature  to  check  its  progress  and  to  preserve,  it  may  be,  a  part  of 
the  joint  from  invasion.  If  the  joint  is  already  involved,  rest  offers 
the  best  opportunity  for  repair  by  preventing  friction  that  stimulates 
the  progress  of  the  disease  and  increases  its  destructive  effects. 
Whatever  checks  or  retards  the  progress  of  the  disease  relieves  its 
symptoms  and  thus  preserves  the  vital  resistance,  both  local  and 
general,  upon  which  the  cure  of  the  disease  ultimately  depends. 
Complete  rest  of  a  diseased  joint  of  the  lower  extremity  necessitates 
in  order  of  importance,  splinting,  stilting  and  traction. 

Splinting  naturally  signifies  the  fixation  that  may  be  attained 
by  the  application  of  a  splint,  extending  a  sufficient  distance  on 
either  side  of  the  part  to  be  fixed. 

Stilting — the  elevation  of  the  foot  from  the  ground  so  that  jar 
and  pressLue  on  the  diseased  articulation  may  be  removed. 

Teaction — a  sufficient  force  exerted  upon  the  limb  to  overcome 
and  to  control  the  spasmodic  action  of  the  muscles. 

The  knee-joint,  the  junction  of  two  levers  of  similar  size  and  func- 
22 


338  TUBERCULOUS  DISEASE  OF   THE  HIP- JOINT 

tion  may  be  easily  fixed  by  apparatus.  But  the  hip-joint  is  a  ball- 
and-socket  joint  -which  permits  free  motion,  and,  being  the  junction 
of  the  trunk  and  the  limb,  two  segments  of  difTerent  size  and  function, 
it  is  especially  difficult  to  control.  For  this  reason  as  much  as  any 
other,  perhaps  the  mechanical  treatment  of  hip  disease  has  been  the 
subject  of  controversy  for  many  years.  And  even  at  the  present 
time  one  can  hardly  describe  it  adequately  without  contrasting  the 
methods  of  treatment  that  are  in  common  use. 

Such  an  exposition  should  begin  naturally  with  a  description  of 
what  has  long  been  known  as  the  American  treatment,  in  which 
traction  has  always  occupied  the  most  important  place.  For 
although  many  of  the  claims  originally  made  for  it  have  been  aban- 
doned, and  although  it  is  no  longer  a  routine  of  orthopedic  clinics, 
it  best  illustrates  certain  preliminary  and  supplementary  details,  of 
the  treatment  that  are  of  value. 

The  Traction  Hip  Splint. — The  traction  hip  splint  consists  of  s. 
pelvic  band  and  an  upright.  The  pelvic  band  is  made  of  sheet  steell 
about  an  eighth  of  an  inch  in  thickness  and  one  and  one-eighth  inches^ 
in  width,  sufficiently  strong  to  support  the  weight  of  the  body  with- 
out yielding,  bent  into  a  U-shape  to  conform  to  the  pelvis,  but  wide 
enough  to  cause  no  anteroposterior  pressure.  As  Taylor  puts  it, 
there  should  be  room  enough  for  the  pelvis  to  move  freely  in  it. 
This  band  embraces  about  three-quarters  of  the  pelvis  at  a  point 
just  above  the  trochanter.  It  is  covered  with  leather,  and  is  pro- 
vided with  a  strap  to  complete  the  circumference.  Upon  the  pelvic 
band  four  buckles  are  placed  for  the  attachment  of  the  perineal 
bands.  The  two  buckles  on  the  front  band  are  placed  directly 
above  the  attachments  of  the  adductor  muscles,  on  either  side  of 
the  genitals.  Behind,  the  buckles  are  placed  much  farther  apart, 
somewhat  to  the  outer  side  of  each  ischial  tuberosity,  upon  which  in 
great  part,  the  weight  of  the  body  is  to  be  supported.  The  pelvic 
band  is  bolted  firmly  to  the  upright  at  a  slight  inclination,  corre- 
sponding to  the  inclination  of  the  pelvis.  The  upright  extends  from 
the  top  of  the  trochanter  to  two  or  more  inches  below  the  sole  of  the 
foot.  It  may  be  made  in  one  piece  or  in  two  sections  overlapped  and 
attached  to  one  another  by  screws  to  allow  for  adjustment  (Fig. 
257).  It  is  turned  inward  at  a  right  angle  below  the  foot  and  is 
shod  with  leather  or  rubber.  The  foot-piece  may  be  provided  with 
a  windlass  (Fig.  257),  or  the  traction  may  be  made  by  simple  straps 
attached  on  either  side  (Fig.  262).  At  about  the  middle  of  the 
upright  is  placed  a  support  of  light  steel,  which  is  provided  with  a 
broad  leather  strap  for  the  purpose  of  fixing  the  thigh  to  the  brace 
and  supporting  the  knee.  In  some  braces  a  second  similar  support 
is  placed  at  the  upper  part  of  the  stem;  in  others  the  knee  is  sup- 
ported only  by  a  broad  leather  pad  which  covers  its  inner  siu-face 
and  is  attached  to  a  cross-piece  on  the  upright  by  straps,  as  in  the 
Taylor  brace,     In  the  Taylor  brace,  which  has  served  as  a  model 


TREATMENT 


339 


for  all  similar  appliances,  the  upright  is  a  steel  tube  into  which  slides 
a  rod,  supporting  the  foot  part  of  the  brace,  the  two  parts  being 
joined  with  a  rack-and-pinion  attachment  and  lock,  so  that  the  brace 
may  be  lengthened  or  shortened  by  means  of  a  key  (Fig.  261). 

Traction  Plasters. — Traction  upon  the  limb  is  made  by  adhesive 
plaster,  preferably  that  known  as  moleskin  (yellow)  plaster,  which 
is  far  less  ii»ritating  to  the  skin  than  rubber  plaster. 


Fig.  256  Fig.  257  Fig.  258 

Figs.  256,  257  and  258. — The  traction  hip  splint,  with  overlapping  upright    and 
windlass,  used  at  the  Boston  Children's  Hospital.     (Bradford  and  Lovett.) 

These  plasters  should  be  cut  to  correspond  to  the  lateral  aspect 
of  the  thigh  and  leg,  thus;  wide  above  and  narrow  below,  reaching 
from  the  trochanter  on  the  outer,  and  from  the  pubes  on  the  inner 
side,  to  the  malleoli  (Fig.  272).  The  lower  ends  are  reinforced  by  a 
second  layer  of  plaster  and  to  them  buckles  are  attached.  The 
plasters  are  then  applied  to  the  limb  and  are  held  in  place  by  a 
bandage  which  is  smoothly  applied  and  then  sewed,  to  prevent  dis- 
arrangement. The  object  of  the  bandage  is  primarily  to  assure  the 
adhesion  of  the  plaster  and  secondarily  to  keep  it  clean.  It  can  be 
replaced  by  a  properly  fitted  covering  of  stockinette  or  by  a  stocking 
leg. 

Another  method  of  applying  the  plaster,  designed  to  obtain  a 


34U 


rUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 


better  hold  upon  the  limb,  is  that  devised  by  Taylor,  and  described 
by  him  as  follows:  "The  first  important  object  is  to  seize  the  leg 
in  such  a  manner  as  to  exert  against  it  an  unyielding  force.  This 
should  be  done  in  such  a  manner  as  will  not  interfere  with  the  circula- 
tion, nor  injure  the  knee,  by  unequal  strain  either  below  or  above  it. 
In  other  words,  the  whole  leg  should  be  grasped  in  such  a  manner  that 
the  knee  will  be  supported.  It  may  be  done  as  follows:  A  strip  of 
adhesive  plaster,  long  enough  to  reach  from  the  waist  to  the  foot. 


Fig.  259  Fig.  260 

Figs.  259  and  260. — C.  F.  Taylor's  method  of  applying  adhesive  plaster. 


and  from  three  to  five  inches  wide  at  the  upper  and  about  one-third 
that  width  at  the  lower  end,  is  taken  and  cut  into  five  tails,  as  shown 
in  the  accompanying  illustration  (Fig.  261).  A  piece  from  4  to  6 
inches  long  is  cut  from  the  centre  tail  and  added  to  the  lower  end 
to  strengthen  it;  and,  if  the  patient  be  strong,  one  or  two  more 
pieces  are  laid  on  the  same  place,  where  a  buckle  is  attached.  Two 
similar  straps  are  prepared,  one  for  the  inside  and  one  for  the  out- 
side of  the  leg,  and  laid  against  the  lateral  aspects  of  the  leg,  the 
ends  with  the  buckles  beginnino:  about  2  inches  above  the  internal 


TREATMENT 


341 


and  external  malleoli,  and  the  centre  tails  reaching  the  entire  length 
of  .the  leg  and  thigh,  to  the  perineum  inside  and  the  trochanter  on 
the  outside.  The  lower  strips  or  tails  are  then  wound  spirally  around 
the  leg  to  the  pelvis  and  afterward  the  other  two  pairs  of  tails,  which 
are  cut  down  to  just  above  the  knee,  are  also  wound  about  the  thigh 
in  the  same  manner.  When  completed  the  thigh  is  involved  in  a 
network  of  strips  of  adhesive  plaster,  which  act  equally  and  without 
pressure  on  the  whole  surface.  The  leg  has  about  one-fourth  of  the 
attachments,  and  the  thigh  three- 
fourths,  which  is  found  to  be  the  right 
proportion  to  protect  the  knee  equally 
from  compression  or  strain.  A  few 
turns  of  the  roller  bandage  are  then 
made  around  the  ankle  just  under  the 
lower  ends  of  the  straps,  which  serves 
as  a  protection  to  the  flesh  under  the 
buckles,  and  then  it  is  continued  over 
the  straps  on  the  whole  leg.  Thus 
prepared,  the  patient  is  ready  for  the 
splint." 

At  the  Boston  Children's  Hospital 
the  lower  ends  of  the  adhesive  straps 
terminate  in  tapes  that  extend  below 
the  foot  for  attachment  to  the  wind- 
lass, which  is  used  with  the  cheaper 
form  of  brace. 

Perineal  Bands. — Perineal  bands  are 
made  by  covering  a  firm,  wide,  un- 
yielding band  of  webbing  with  several 
folds  of  blanket  or  similar  material 
and  then  binding  it  smoothly  with 
canton  flannel.  These  are  made  in 
dift'erent  lengths  and  sizes,  as  may  be 
required. 

The  "High  Shoe."— The  best  and 
lightest  material  for  raising  the  shoe 
worn  on  the  sound  foot  to  correspond 
with  the  brace  is  cork,  and  the  ordi- 
nary thickness  is  2|  inches.     A  good 

and  cheap  substitute  may  be  made  of  light  wood  provided  with  a 
leather  sole,  and  in  certain  cases  a  patten  of  metal  may  be  used. 

The  Application  of  the  Traction  Hip  Splint. — The  traction  brace  is 
applied  in  the  following  manner: 

The  patient  lying  upon  his  back,  the  pelvic  band  is  first  adjusted 
and  is  strapped  about  the  body.  The  perineal  supports  are  then 
drawn  firmly  into  place  so  that  pressm-e  on  the  upright  does  not 
move  the  pelvic  band  from  its  proper  position,  just  above  the  tro- 


FiG.  261. — The  original  trac- 
tion hip  brace  provided  with  an 
abduction  screw  and  a  strap  to 
regulate  the  inclination  of  the 
pelvic  band  on  the  upright. 


342 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


chanter.  The  brace  is  then  pushed  upward  against  the  resistance 
of  the  perineal  bands,  while  the  limb  is  at  the  same  time  drawn 
downward  and  is  fixed  by  attaching  the  straps  to  the  buckles  at  the 
ends  of  the  adhesive  plasters.  If  the  brace  is  provided  with  a  wind- 
lass or  ratchet,  further  traction  is  applied  to  the  point  of  tolerance 
by  means  of  the  key,  care  being  taken  in  adjusting  the  brace  that 


c 


Fig.  262.- 


-The  Judson  brace.     This  has  but  one  perineal  band,  and  the  upright 
is  bolted  firmly  to  the  pelvic  band. 


it  does  not  project  so  far  below  the  foot  as  to  more  than  equal  the 
extra  length  provided  by  the  high  shoe  on  the  sound  side.  The 
knee  band  is  then  adjusted  and  in  many  instances  a  strap  is  placed 
about  the  ankle  and  the  brace  to  assure  greater  security.  The  shoe 
is  then  put  on,  the  leg  clothing  is  drawn  over  the  brace,  and  the 
patient  is  allowed  to  stand.  If  in  walking  the  patient  is  incHned  to 
tilt  the  foot  downward  and  to  bear  the  weight  on  the  toe,  a  strap  is 
attached  to  the  middle  of  the  foot-piece  and  fastened  to  a  buckle  on 
the  heel  of  the  shoe  with  sufficient  tension  to  hold  the  foot  in  the 
horia)ntal  position. 


TREATMENT 


343 


By  means  of  this  brace  the  weight  is  borne  entirely  upon  the  peri- 
neal bands;  thus  the  joint  is  reheved  from  pressure  and  from  jar. 
The  perineal  bands  should  be  accurately  adjusted  to  pass  upward 
in  front,  parallel  to  one  another  on  either  side  of  the  genitals,  in 
order  to  avoid  pressure  on  the  inner  borders  of  the  thighs;  while 
behind  they  turn  diagonally  outward  in  order  to  pass  over  the  tuber- 
osities, which  are  best  adapted  for  weight-bearing. 

In  the  original  Taylor  hip  brace  the  pelvic  band  is  bolted  to  the 
upright  in  a  manner  to  permit  anteroposterior  motion,  and  the 
inclination  of  the  pelvic  band  is  regulated  by  a  strap  attached  to 
the  upright  for  better  adjustment  (Fig.  261),  when  the  limb  is  flexed 


Fig.  263.— The  Bradford  brace. 


to  a  marked  degree.  This  brace  has  been  modified  by  Taylor  by 
shortening  and  changing  the  shape  of  the  pelvic  band  for  the  use  of 
but  one  perineal  support  (Fig.  272);  and  a  similar  form  of  brace 
is  used  by  Judson.  The  shortened  pelvic  band  lessens  the  restraint 
of  the  brace  upon  the  motion  of  the  limb,  and  seems  to  ofter  little 
compensating  advantage. 

Bradford  now  uses  a  mpdification  of  the  Thomas  knee  splint  with 
an  attachment  to  prevent  adduction.  This  provides  a  solid  support 
for  the  perineum  and  better  fixation  of  the  joint. 

Before  the  traction  brace  is  used  in  ambulatory  treatment,  dis- 


34J:  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

tortion  of  the  limb,  if  it  be  present,  should  be  reduced;  or  if  the  dis- 
ease is  particularly  acute,  preliminary  rest  in  1)e(l  until  the  subsidence 
of  the  symptoms  is  ad^'isable. 

The  Reduction  of  Deformity  by  Means  of  the  Traction  Brace. — 
The  patient  lies  in  bed  upon  a  firm  mattress;  the  distorted  limb  is 
then  raised  to  slightly  more  than  a  sufficient  angle,  to  relax  the  con- 
tracted muscles  and  to  straighten  the  lumbar  lordosis ;  it  is  then 
abducted  or  adducted  if  necessary  until  the  level  of  the  pelvis  is 
restored.  The  pelvic  band  is  made  to  conform  to  this  greater 
relati\'e  inclination  of  the  pelvis  by  lengthening  the  posterior  strap ; 
the  brace  is  then  applied,  the  limb  being  held  in  the  attitude  of  de- 
formity by  a  sling  or  support  (Fig.  264),  and  as  much  traction  as  the 
patient  can  tolerate  is  exerted  by  lengthening  the  upright.  The  direct 
traction  exerted  by  the  brace  may  be  reinforced  by  means  of  a  cord 
running  over  a  pulley  at  the  foot  of  the  bed,  in  the  line  of  the  brace, 
to  which  a  weight  of  10  or  more  pounds  (Fig.  271)  is  attached.  Thus 
the  pressure  of  the  perineal  bands  is  somewhat  lessened.  Efficient 
traction  will  quickly  reduce  recent  deformity  caused  by  muscular 
contraction,  and  as  this  is  lessened  the  position  of  the  limb  is  cor- 
respondingly changed  until  it  lies  extended  and  parallel  with  its 
fellow.  If  adduction  is  combined  with  flexion  the  perineal  band  on 
the  side  opposite  to  the  disease  is  tightened  from  time  to  time,  or  a 
direct  push  against  the  opposite  adductor  region  may  be  exerted 
by  means  of  a  bar  attached  to  the  brace  opposite  the  knee  (Fig.  300). 
In  ordinary  cases  the  deformity  may  be  reduced  by  this  means  in 
from  two  to  six  weeks. 

If,  as  in  most  instances,  the  brace  is  not  at  immediate  command 
the  deformity  may  be  reduced  by  direct  traction. 

Reduction  of  Deformity  by  the  Weight  and  Pulley. — The  traction 
plasters  are  applied  to  the  limb  in  the  manner  already  described, 
and  the  patient  is  placed  on  his  back  on  a  narrow,  firm  mattress. 
The  limb  is  raised  until  the  lumbar  vertebrae  rest  upon  the  bed  and 
it  is  then  moved  to  one  or  the  other  side,  if  lateral  distortion  is  pres- 
ent, until  the  level  of  the  pelvis  is  restored.  In  this  position  the 
limb  is  supported  on  a  pillow,  or  better,  on  the  adjustable  triangle 
used  with  the  traction  hip  splint  (Fig.  264).  A  pulley  is  then 
attached  to  the  foot  of  the  bed  in  a  prolongation  of  the  line  of  the 
flexed  limb.  The  wheel  may  be  screwed  to  the  top  of  a  narrow 
board,  which  may  be  raised  or  lowered  on  the  foot  of  the  bed  as 
required.  To  the  buckles  on  the  plaster  traction  straps  a  stirrup 
carrying  the  cord  is  attached.  This  stirrup  is  simply  a  spreader  of 
narrow  thin  wood,  slightly  wider  than  the  foot,  provided  at  either 
end  with  straps  or  tapes,  its  purpose  being  to  prevent  direct  pressure 
on  the  malleoli  (Fig.  270).  By  means  of  a  weight  suspended  at  the 
foot  of  the  bed  traction  is  made  upon  the  limb  to  the  extent  that  the 
comfort  of  the  patient  will  permit.  As  in  Buck's  system  of  traction, 
the  foot  of  the  bed  may  be  raised  to  increase  the  friction  of  the  body 


TREATMENT 


345 


and  thus  to  counteract  the  traction  force,  but  in  the  treatment  of 
children  this  is  inefficient  and  counter-traction^mustjbe'provided.  A 
simple  method  is  to  attach  two  perineal  bands,  asjdescribed  in  con- 
nection with  the  traction  brace,  to  strong  tapes  that  pass  above'and 
below  the  patient's  body,  to  be  fixed  to  the  head  of  the  bed  at  a  suit- 
able distance  from  one  another;  thus  the  pelvis  is  supported  by 
prolonged*  perineal  bands. 


Fig.  264. — The  reduction  of  flexion  by  means  of  the  traction  hip  splint. 

(C.  F.  Taylor.) 

In  order  to  assure  efficient  and  constant  traction  the  patient  must 
be  prevented  from  sitting  up.  For  this  purpose  a  swathe  about 
the  body  or  shoulder  straps  may  be  applied  and  attached  to  the  bed. 

A  convenient  appliance  is  that  of  Marsh:  "This  consists  of  a 
piece  of  webbing,  passing  across  the  front  of  the  chest  and  ending 
in  two  loops,  through  which  the  two  arms  are  passed,  and  through 
which  is  threaded  another  piece  of  stout  webbing  which  runs  trans- 
versely across  the  surface  of  the  bed  under  the  child's  shoulders, 
and  is  fastened  at  its  two  ends  to  the  sides  of  the  bedstead.  When 
this  is  in  action  the  patient's  shoulders  are  kept  flat  on  the  bed,  so 


I 


w 


Fig.  265. — Weight  extension  acting  as  leverage  in  hip  disease:  P,  pulley;  W,  weight; 
F,  fulcrum.      (Howard  Marsh.) 

that  he  can  neither  sit  up  nor  turn  on  his  side.  This  chest  band  does 
not  cause  the  slightest  discomfort.  It  is  not,  of  course,  fixed  tightly, 
and  when  the  child  finds  that  he  cannot  sit  up  he  makes  no  further 
attempt  to  do  so;  and  as  he  lies  flat  the  band  is  loose." 

It  is  often  of  advantage,  particularly  if  the  disease  is  active,  to 
use  some  form  of  apparatus  to  fix  the  patient  more  thoroughly. 
Marsh  uses  a  long  lateral  splint  of  thin  board  reaching  from  the  axilla 


346 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINf 


to  a  crossbar  below  the  sole  of  the  foot.     To  this  the  patient's  body 
and  sound  limb  are  bandaged  (Fig.  267) . 

For  the  same  purpose^a  plaster  spica  bandage  or  a  Thomas  splint 
may  be  applied  on  the  sound  side,  but  a  more  convenient  appliance 
is  the  frame  of  gas-pipe  covered  with  canvas  that  has  been  described 
in  the  chapter  on  Pott's  disease.  Upon  this  frame  the  patient  can 
be  fixed,  the  limb  being  elevated  by  a  support  attached  to  the  frame 


Fig.  266. — Posture  of  the  limb  in  hip  disease  in  which  traction  should  be  applied  in 
order  to  avoid  leverage.     P,  pulley;  W,  weight;  F,  fulcrum.    (Howard  Marsh.) 

or  independent  of  it  (Figs.  268  and  269).  It  is  perhaps  needless  to 
suggest  that  the  bedclothes  must  be  held  from  the  elevated  limb; 
in  fact,  that  the  patient  must  for  a  time  be  enclosed  in  a  tent  of  bed- 
clothes if  the  deformity  is  extreme.  At  first  the  traction  weight 
must  not  be  great,  but  as  the  perineum  becomes  accustomed  to 
pressure  as  much  weight  as  can  be  tolerated  is  used,  from  ten  to 
twenty  pounds  being  the  average.  This  may  be  reduced  at  night  and 


Fig.  267. — Traction  in  hip  disease.   Marsh's  method  of  fixing  the  patient  in  bed  with 
shoulder  straps  and  a  long  T-splint  on  the  sound  side.      (Howard  Marsh.) 

increased  during  the  day.  Great  care  must  be  taken  to  prevent 
painful  pressure  on  the  perineum  by  careful  adjustment  and  fre- 
quent inspection  of  the  perineal  bands. 

If  the  frame  is  used  it  may  be  provided  with  a  windlass  at  the 
bottom  for  traction  and  with  an  arched  band  of  metal  across  the 
pelvis  for  the  attachment  of  the  perineal  bands,  which  behind  are 
fastened  to  the  side  bars  at  a  higher  level.     Thus  the  frame  may  be 


TREATMENT 


347 


made  an  independent  recumbent  splint  on  which  the  patient  may  be 
moved  about.  If,  however,  one  desires  to  exert  traction  to  the 
point  of  ditraction,  the  weight  and  pulley  arrangement  is  more 


Fig.  268. — Traction  by  means  of  weight  and  pulley.      (R.  T.  Taylor.) 

satisfactory;  in  this  case  the  limb  should  be  placed  in  an  attitude  of 
slight  flexion  and  abduction,  so  that  the  femur  may  be  drawn  more 
directly  from  the  acetabulum. 


Fig.  269. — Method  of  fixing  the  patient  to  the  Bradford  frame  for  traction  in  hip 
disease.     (R.  T.  Taylor.) 

Lateral  Traction. — Thus  far  longitudinal  traction  has  been  con- 
sidered, but  lateral  traction  or  traction  in  the  line  of  the  neck  of 
the  femur  deserves  some  consideration. 


348 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


Mr.  Thomas,  who  condemned  all  forms  of  traction  as  deceptive 
and  irrational,  and  especially  longitudinal  traction,  speaks  thus  of 
lateral  traction:  "For  surely  if  relief  from  pressure  be  required,  the 
only  direction  in  which  this  is  possible  is  clearly  in  the  axis  of  the 
neck  of  the  femur.     Any  method  of  extension  in  the  axis  of  the  body 


Fig.  270. — Lateral  and  longitudinal  traction  in  hip  disease.      (Page.) 

merely  transfers  the  pressure  from  the  upper  part  of  the  acetabulum 
to  the  lower  quarter.  "^  This  contention  is  purely  theoretical,  as 
there  is  no  evidence  to  show  that  injurious  pressure  is  exerted  upon 
part  of  the  acetabulum.  On  the  contrary,  the  specimens  from  sub- 
jects who  have  been  treated  by  longitudinal  traction  in  recumbency 


Fig.  271. — A  method  of  reducing  flexion  in  hip  disease.  The  long  brace  is  adjusted 
to  the  angle  of  deformity,  and  in  addition  to  the  direct  traction  of  the  apparatus 
weights  are  attached  to  the  brace  itself.  In  the  illustration  counter-traction,  by  means 
of  perineal  bands  attached  to  the  head  of  the  bed,  is  shown. 

and  by  means  of  the  traction  hip  splint  almost  invariably  show  the 
effect  of  pressure  upon  the  upper  part  of  the  head  of  the  femm-  and 
upon  the  upper  adjoining  margin  of  the  acetabulum.  INIoreover, 
the  neck  of  the  femur  is  in  childhood  so  short  and  is  set  upon  the 

1  Loc.  cit.,  p.  10. 


TREATMENT  349 

shaft  at  so  great  an  angle  that  longitudinal  traction,  if  the  limb  is 
slightly  abducted,  is,  practically  speaking,  in  the  line  of  the  neck 
so  that  even  from  the  theoretical  stand-point  the  question  of  injurious 
pressure  could  only  arise  in  the  treatment  of  adults.  The  advantage 
of  lateral  traction  in  the  treatment  of  hip  disease  was  urged  by 
Phelps^  as  early  as  1889,  and  it  has  been  applied  as  a  routine  practice 
in  ambulatbry  treatment  by  Blanchard,^  of  Chicago,  since  1872. 

The  effect  of  lateral  traction  in  recumbency  has  been  carefully 
investigated  by  C.  G.  Page.=^  His  conclusions  are  that  lateral 
traction  alone  is  of  no  benefit,  but  if  applied,  together  with  longi- 
tudinal traction,  it  gives  great  relief  in  certain  acute  cases.  The 
longitudinal  traction  should  be  twice  as  great  as  the  lateral,  10  and 
5  pounds  being  the  average  weights  employed  in  his  experiments. 
The  method  is  shown  in  the  illustration  (Fig.  270) . 

The  brace  should  be  worn  day  and  night.  .The  perineal  bands 
may  be  loosened  at  times  to  permit  cleansing  the  skin  with  alcohol 
and  for  powdering,  in  order  that  the  skin  may  be  kept  dry;  but  at 
such  times,  if  the  disease  be  acute,  manual  traction  should  be  made 
until  the  brace  has  been  readjusted.  The  adhesive  plasters,  if  of 
moleskin,  may  often  remain  in  position  for  three  months  or  longer. 
When  they  are  removed  the  limb  is  gently  bathed  with  alcohol. 
Excoriations  are  unusual  unless  rubber  plaster  is  used.  If  the  skin 
is  abraded  the  part  should  be  powdered  with  boracic  acid  and  pro- 
tected from  the  plaster  by  a  layer  of  gauze. 

The  Relative  Efficiency  of  the  Traction  Hip  Splint. — In  analyzing 
the  action  of  this  brace  it  is  evident  at  once  that  it  is  thoroughly 
effective  as  a  stilt.  It  is  effective  as  a  traction  appliance,  in  the 
sense  of  relieving  muscular  tension,  in  direct  proportion  to  the  care 
that  is  exercised  in  its  adjustment.  Traction  by  this  appliance  may 
be  made  constant  and  effective,  even  to  the  point  of  practical  fixation 
while  the  patient  is  in  bed,  or  when  crutches  are  used,  in  ambulatory 
treatment.  But  when  the  apparatus  is  used  in  locomotion  the  trac- 
tion straps  alternately  relax  and  tighten  as  the  weight  of  the  body 
falls  upon  and  leaves  the  brace  in  walking.  When  the  brace  is  off 
the  ground  the  joint  is  subjected  to  the  traction  that  the  brace  exerts, 
plus  its  weight,  as  contrasted  with  cessation  of  traction  and  the  relief 
from  the  weight  when  the  brace  supports  the  body  at  the  alternate 
step.  Thus  the  critics  of  the  brace  assert  that  it  exercises  a  pumping 
action  of  the  joint.  As  a  matter  of  fact,  the  observation  of  patients 
under  treatment  by  this  method  will  show  that  little  actual  traction 
is  exerted  in  the  ordinary  cases;  that  the  so-called  traction  really 
serves  principally  for  the  adjustment  of  the  brace,  which  by  its 
weight  exercises  a  certain  intermittent  traction  during  locomotion. 
The  hold  of  the  encircling  band  upon  the  pelvis  assures  a  consider- 
able restriction  of  motion;  but  whatever  splinting  action  it  may 

1  New  York  Med.  Rec,  May  4,  1889.  2  Xr.  Am.  Orthop.  Assn.,  vii. 

3  Boston  Med.  and  Surg.  Jour.,  September  13,  1894. 


350  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

have  depends  upon  the  degree  of  traction,  which  is  never  effective 
enough,  however,  to  prevent  a  certain  amount  of  motion;  according 
to  the  experiments  of  Lovett,  a  range  of  at  least  35  degrees  even  when 
the  brace  is  properly  adjusted.^ 

The  traction  hip  splint  was  not  intended  to  be  a  fixation  or  splint- 
ing appliance.  On  the  contrary,  Davis,  its  inventor,  Taylor,  who 
changed  it  into  a  practicable  form,  and  Sa^Te,  who  further  modified 
it,  each  believed  that  motion,  except  when  the  joint  was  fixed  by 
muscular  spasm,  was  desirable  as  a  means  of  preserving  function 
and  that  the  traction  permitted  it  without  friction. 

^Motion  without  friction  in  this  sense  would  seem  to  imply  actual 
separation  of  the  opposed  bones,  or  distraction  as  distinct  from 
traction.  That  actual  distraction  is  possible  at  the  hip-joint  both 
in  health  and  disease  is  proved  by  the  experiments  of  Brackett-  and 
by  those  of  Bradford  and  Lovett.  These  experiments  show  that  a 
traction  force  from  ten  to  twenty  pounds  is  required  to  cause  one- 
eighth  to  one-ciuarter  of  an  inch  of  actual  lengthening  of  the  limb, 
even  in  childhood,  although  if  the  muscles  are  atrophied  and  the  joint 
disorganized  by  disease  a  much  less  weight  will  separate  the  joint 
sm-f  aces  as  may  be  demonstrated  by  .r-ray  pictmes.  Under  ordinary 
conditions,  however,  it  is,  to  say  the  least,  unlikely  that  the  feeble 
and  intermittent  traction  exerted  by  a  hip  splint,  when  used  as  an 
ambulatory  support,  can  be  sufficient  to  separate  the  bones  from  one 
another  or  even  to  relieve  the  muscular  spasm  that  causes  deformity. 

At  the  present  time  the  theory  that  motion  in  a  joint  of  which  the 
component  bones  are  actually  diseased  is  of  benefit,  or  even  that  it 
is  harmless,  has  few  supporters  even  among  those  who  use  the  trac- 
tion brace  exclusively.  On  the  contrary,  the  motion  that  cannot 
be  prevented  is  excused  because  it  is  believed  that  no  more  effective 
protection  can  be  attained  by  any  method  of  ambulatory  treatment. 

In  all  acute  cases  a  period  of  rest  in  bed  with  traction  to  the  point 
of  actual  distraction  is  advised.  When  ambulation  is  resmned  the 
braced  limb  is  made  pendent  by  means  of  the  high  shoe  and  crutches, 
so  that  uninterrupted  traction  may  still  be  exerted,  and  the  brace 
is  only  used  as  a  supporting  appliance  when  the  symptoms  indicate 
that  the  disease  is  quiescent. 

In  hospital  practice,  the  decisive  test  of  efficiency,  the  original 
hip  brace  has  been  in  great  degree  discarded  as  ineftective  in  reliev- 
ing the  s^Tnptoms  and  in  preventing  deformity. 

In  its  place  the  long  traction  brace  in  some  form  is  now  used  as 
providing  better  fixation. 

This  is  illustrated  in  Fig.  272.  To  the  pelvic  band  of  the  traction 
brace  a  bar  is  attached  which  extends  in  the  axillary  line  to  about 
the  middle  of  the  scapula  where  it  supports  a  chest  band  of  thin 

1  R.  TV.  Lovett:  New  York  :Med.  Jour..  August  8,  1891. 

2  Brackett:  Tr.  Am.  Orthop.  Assn.,  ii;  Bradford  and  Lovett:  New  York  Med. 
Jour.,  August  4,  1894. 


TREATMENT 


351 


metal  covering  about  three-fourths  of  the  thorax,  the  circumference 
as  at  the  pelvis  being  completed  by  a  strap.  The  brace  should  be 
constructed  so  as  to  hold  the  limb  in  about  15  degrees  of  abduction. 
If  it  is  properly  adjusted,  it  assures  practical  fixation  of  the  joint. 

The  efficiency  of  the  apparatus  may  be  still  further  increased  by 
replacing  the  perineal  bands  with  a  metallic  ring.  This  ring,  which 
fits  the  upper  extremity  of  thigh  closely,  is  attached  to  the  upright 
at  an  inclination  corresponding  to  the  line  of  the  groin  (Fig. 
274).  (The  Thomas  ring  is 
described  fully  in  connection 
with  his  knee  splint.)  It  is  a 
better  support  because  it  pre- 
vents anteroposterior  motion 
within  the  pelvic  band,  which 
the  perineal  straps  permit. 
The  ring  may  be  used  as  the  only 
support  or  it  may  be  combined 
with  a  perineal  band  on  the  op- 
posite side.  This  is  of  advan- 
tage if  there  is  a  tendency 
toward  adduction. 

The  apparatus  is  most  satis- 
factory when  the  hollow  upright 
of  the  Taylor  brace  is  used. 
This  is  light  and  strong,  and  is 
provided  with  an  arrangement 
for  efi'ective  traction,  but  in 
hospital  practice  the  upright  is 
made  of  solid  metal,  and  the 
traction  is  made  by  simple 
straps.  The  metallic  ring, 
besides  providing  better  fix- 
ation, is  a  firm  support  that 
cannot  be  removed  by  the  pa- 
tient. It  is,  of  course,  more 
difficult  of  adjustment,  and  it 
is  not  suited  to  the  treatment  of 
young  children  because  of  the 
difficulty  in  keeping  it  clean  and 
dry. 

The  Thomas  ring  was  first  applied  to  a  hip  splint  by  Phelps 
(Fig.  276).  He  urged  the  advantages  of  fixation  and  traction,  and 
his  brace,  of  which  that  last  described  is  simply  a  slight  modification, 
is  provided  with  an  arrangement  for  lateral  traction.  Practically 
speaking,  this  is  a  tape  by  which  the  lower  thii'd  of  the  thigh  is  held 
in  apposition  to  the  upright.  It  hardly  seems  possible  that  appreci- 
able lateral  traction  can  be  exerted  on  the  joint  by  this  means  if  the 


Fig.  272. — The  long,  inexpensive  brace, 
with  soHd  upright,  showing  the  perineal 
bands  and  the  adhesive  plaster,  as  used  in 
hospital  practice. 


•Jo.: 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


Fig.  273. — The  long  hip  splint  applied. 


^ft^'i^l 

H  1  ~    i    jjH 

Fig.  274. — The  long  brace,  with 
Thomas  ring  and  extension  upright, 
similar  to   Phelps'   brace. 


Fig.  275. — Rear  view  of  brace. 


TREATMENT 


353 


metalic  ring  is  properly  fitted  to  the  thigh.  The  simple  straps  do 
not  afford  as  effective  traction  as  the  rack  and  pinion,  nor  is' the  brace, 
as  usually  constructed,  sufficiently  strong  to  bear  the  weight  of  the 
body  without  bending.  It  should  be  stated,  however,  that  this 
form  of  brace  is  intended  to  be  used  with  crutches  rather  than  as  a 
walking  appliance. 

Certain  objections  to  this  attempt  to  combine  effective  splinting 
with  traction  and  stilting  have  been  urged  by  those  who  believe 
in  the  efficiency  of  the  ordinary  traction  brace.  For  example,  it  is 
said  that  the  splinting  is  ineffective  because  the  movements  of  the 
trunk  are  transmitted  to  the  joint,  while  this  is  not  true  of  braces 
that  do  not  extend  above  the  pelvis. 


Fig.  276.- 


-The  Phelps  hip 

spUnt. 


Fig.  277. — A  chair  to  be  used  with  the  long  hip 
splint.  The  patient  sits  upon  the  sound  side,  while 
the  splinted  half  of  the  body  remains  in  the  extended 
position,  the  brace  resting  on  the  floor. 


As  a  matter  of  experience,  it  will  be  found  that  motion  of  the 
upper  part  of  the  trunk  is  absorbed,  as  it  were,  in  the  flexible  lumbar 
region  of  the  spine  before  it  reaches  the  joint.  If,  however,  such 
motion  or  any  motion  causes  discomfort  or  aggravates  the  symptoms, 
the  patient  should  be  confined  in  the  recumbent  posture  until  the 
acute  phase  of  the  disease  has  passed.  It  is  said  that  the  brace  is 
cumbersome,  that  the  patient  cannot  sit  with  comfort,  and  that  it 
2.3 


354  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

prevents  normal  activity.  A  long  brace  certainly  weighs  more  than 
a  short  one,  and  if  a  brace  prevents  flexion  of  the  hip  and  spine  it  is 
evident  that  the  patient  cannot  sit  with  comfort  in  an  ordinary 
chair. 

The  patients  themselves,  however,  make  little  complaint  of  the 
brace,  even  when  it  has  been  substituted  for  an  ordinary  traction 
splint;  while  the  greater  restraint  of  activity  is  a  favorable  element 
of  treatment,  since  children  who  do  not  suffer  pain  are  much  more 
likely  to  be  too  active  than  to  be  harmfully  restrained  by  any  form 
of  apphance.  These  objections  are  trivial  if  one  is  convinced  that 
the  dangerous  and  deforming  disease  that  is  under  treatment  may 
be  more  easily  controlled  and  that  the  final  result  is  likely  to  be 
better  and  to  be  more  rapidly  attained  by  this  means  than  by 
another. 

The  Thomas  Treatment  of  Hip  Disease. — H.  0.  Thomas,^  of  Liver- 
pool, writing  at  a  time  when  in  America  it  was  generally  believed 
that  motion  was  essential  to  the  well-being  of  a  diseased  joint,  and 
when  fixation  was  supposed  to  predispose  to,  or  to  actually  induce, 
anchylosis,  states  "  that  continuity  of  extension  per  se  is  not  a  remedy 
in  hip-joint  disease;  in  its  application  it  involves  unavoidably  a 
fractional  degree  of  fixation  which  is  sufficient  to  mask  the  evil  of 
this  ridiculous  malpractice." 

The  conclusions  on  which  his  treatment  is  based  are  these : 

"The  main  obstacle  to  the  cure  of  an  inflamed  joint  is  the  friction 
and  pressure  of  its  surfaces;  consequently  the  attainment  of  rest, 
that  is,  of  immobility  of  the  articulation,  ought  to  be  the  principle 
which  should  guide  the  treatment.  Pressure  and  concussion  are  less 
to  be  feared  than  friction.  Effectual  rest  can  only  be  obtained  by 
mechanical  treatment,  and  for  this  pmpose  the  appliances  which  I 
here  recommend  are  effectual.  The  more  an  inflamed  joint  is  moved 
the  stiff er  does  it  become;  while  the  more  effectually  it  is  fixed,  the 
sooner  and  the  more  completely  is  its  capability  of  movement 
restored.  To  ensure  permanency  of  cure  the  control  should  be 
maintained  for  a  period  beyond  the  time  when  resolution  has  taken 
place.  This  prolonged  arrest  of  a  joint's  movements,  for  even  an 
unnecessarily  long  period,  I  have  never  found  to  do  harm." 

Thomas'  conclusions  have  now  been  generally  accepted  although 
his  methods  are  rarely  used  in  this  country. 

The  Thomas  hip  splint  is  described  by  him  substantially  as 
follows : 

A  flat  piece  of  malleable  iron,  three-quarters  of  an  inch  wide  and 
three-sixteenths  of  an  inch  thick  for  children,  and  one  inch  by  one- 
quarter  inch  for  adults,  long  enough  to  extend  from  the  lower  angle 
of  the  scapula  to  the  middle  of  the  calf,  forms  the  upright.  This  is 
fitted  to  the  body  of  the  patient,  passing  from  the  lower  angle  of  the 

1  Diseases  of  the  Hip-,  Knee-,  and  Ankle-joints  Treated  by  a  New  and  Effective 

Method,  1S75.  p.  10. 


TREATMENT 


355 


scapula,  in  a  perpendicular  line,  downward,  over  the  lumbar  region, 
across  the  pelvis,  slightly  external,  but  close  to  the  posterior  spinous 
process  of  the  ilium  and  the  prominence  of  the  buttock,  along  the 
course  of  the  sciatic  nerve  to  a  point  slightly  external  to  the  calf  of 
the  leg.  It  must  be  carefully  modelled  to  this  track.  The  lumbar 
portion  of  the  upright  must  be  invariably  almost  a  plane  surface, 
but  it  must  be  twisted  slightly  on  its  long  axis  at  the  junction  of  the 
upper  and  middle  third,  so  that  the  anterior  surface  of  the  lower  part 
may  look  slightly  outward  to  correspond  to  the  contour  of  the  but- 
tock and  thigh.  A  second  and  double  bend  is  made  in  the  upright 
at  the  point  where  it  passes  the  buttock,  so  that  the  thigh  part  lies 
on  a  slightly  higher  plane  than  the  body  part,  but 
m.  dil  _^M|  parallel  with  it.  The  upright  is  ther  provided 
tjlllf'        ^3J^    with  chest,  thigh,  and  leg  bands  (Fig.  278). 

The  chest  band  is  of  hoop  iron,  one  and  a  half 
inches  in  width  by  one-eighth  of  an  inch  in  thick- 
ness. This  is  bent  into  an  oval  to  correspond 
with  the  shape  of  the  chest,  being  four  inches 
less  than  the  circumference  at  this  point  if  the 


Fig.     278.  The  Fig.  279. — The  Thomas  hip  splint,  covered  and  fitted  with 

splint  in  its  simplest  shoulder  straps.     (Ridlon  and  Jones.) 

form,  not  yet  padded 
or  covered.   (Ridlon.) 


patient  is  an  adult,  and  of  a  corresponding  size  for  a  child.  It 
is  riveted  to  the  upper  extremity  of  the  brace,  so  that  one-third 
of  its  length  shall  be  on  the  side  corresponding  to  the  diseased 
joint  and  two-thirds  on  the  other.  The  thigh  band  and  leg 
band  are  of  similar  material,  three-quarters  by  one-eighth  of 
an  inch  in  size.  The  thigh  band,  in  length  equal  to  two- 
thirds  of  the  circumference  of  the  thigh,  is  fastened  to  the  up- 
right at  a  point  one  or  two  inches  below  the  buttock,  and  the  calf 
band,  equal  in  length  to  half  the  circumference  of  the  leg  at  the  calf, 
is  riveted  to  the  lower  extremity  of  the  brace.  Both  the  thigh  and 
leg  bands  are  attached  to  the  brace  at  points  slightly  to  the  inner 


356- 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 


side  of  the  centre,  so  that  the  outer  arm  of  each  band  is  somewhat 
longer  than  the  inner.  The  brace  is  padded  with  thin  boiler  felt 
and  is  covered  smoothly  with  basil  leather.  In  fitting  the  brace  to 
the  patient  the  long  part  of  the  chest  band  should  be  made  to  hug 
the  body  closely,  while  the  short  arm  should  be  somewhat  away  from 
it.  The  anterior  surface  of  the  thigh  part  of  the  upright  should  have 
a  perceptible  outward  twist  and  should  be  somewhat  on  the  inner 
side  of  the  popliteal  space.  Thus  the  instrument  is  prevented  from 
rotating  outward  and  becoming  a  side  splint.  The  chest  band  is 
closed  with  a  strap  and  buckle;  it  is  suspended  by  shoulder  straps, 
and  the  leg  between  the  two  bands  is  attached  to  the  brace  by  means 
of  a  flannel  bandage.     Ridlon  states  that  in  practice  this  bandage 


Fig.  280. — ]\Iethod  of  changing  the  line  of  pressure  on  the  skin  from  the  Thomas 
hip  splint  by  draw-ing  the  tissues  to  one  side.      (Ridlon  and  Jones.) 

is  usually  replaced  by  a  strip  of  basil  leather  passed  across  the  front 
of  the  limb  close  down  to  the  upper  border  of  the  patella,  thence 
backward  and  downward  to  the  stem  of  the  splint  and  pinned  to  the 
covering,  so  that  the  resistance  to  the  downward  working  of  the 
brace  is  borne  by  the  quadriceps  femoris  muscle.  The  ordinary 
shoulder  straps  may  be  replaced  by  a  single  bandage  looped  about 
the  upper  part  of  the  stem  (Fig.  280).  This  bandage  is  twisted  for 
a  length  of  about  six  inches,  then  separated,  the  ends  being  carried 
over  the  shoulders,  are  passed  through  holes  in  the  corresponding 
ends  of  the  chest  band,  where  they  are  knotted,  and  finally  the  two 
ends  are  tied  to  one  another,  completing  the  circumference  of  the 
chest  band. 


TREATMENT  357 

This  brace  is  fitted  by  the  surgeon  directly  to  the  patient's  body 
as.  he  stands  erect.  If  the  hmb  is  already  flexed  the  foot  is  raised 
by  blocks  until  the  lumbar  lordosis  is  straightened;  the  brace  is  then 
bent  to  fit  the  angle  of  deformity  and  is  applied  in  the  usual  manner. 

The  brace  is  made  of  iron  because  it  is  less  elastic  than  steel,  and 
because  it  can  be  more  easily  twisted  by  wrenches.  It  must  be 
heavy  and  strong  in  order  to  splint  the  part  effectively,  and  it  can 
only  be  an  effective  splint  when  it  is  fixed  in  its  proper  position  and 
exercises  direct  pressure  upon  the  hip-joint.  In  cases  in  which  the 
brace  has  been  properly  adjusted  a  deep  furrow  should  appear  in 
the  buttock  directly  over  the  neck  of  the  femur.  Once  fitted  to  the 
patient  it  is  changed  only  at  infrequent  intervals  and  always  by  the 
surgeon,  who  is  particularly  careful  not  to  move  the  limb  during 
the  active  stage  of  the  disease. 

The  double  Thomas  hip  splint  is  made  by  joining  two  single 
splints.  These  are  riveted  to  the  chest  band  above  and  are  con- 
nected at  the  lower  ends  by  a  crossbar  unless  the  brace  is  to  be  used 
in  the  reduction  of  deformity.  Care  must  be  taken  that  the  up- 
rights pass  to  the  outer  side  and  not  directly  over  the  postero- 
superior  spines  of  the  ilium. 

The  Reduction  of  Deformity  by  the  Thomas  Method. — Preferably 
in  the  treatment  of  children  the  double  brace  is  applied,  the  sound 
limb  being  fixed  in  the  extended  position  while  the  flexed  limb  is 
supported  by  the  other  arm  of  the  brace,  bent  to  the  angle  of  deform- 
ity. The  patient  is  confined  to  the  bed  and,  as  the  muscular  spasm 
relaxes  under  the  influence  of  enforced  rest,  the  brace  is  straightened 
slightly  by  wrenches  from  time  to  time,  at  a  point  opposite  the  joint, 
to  conform  to  the  improved  position  until  symmetry  is  restored.  In 
resistant  cases  this  gradual  relaxation  is  hastened  by  straightening 
the  brace  somewhat  at  intervals,  to  which  the  attached  limb  must 
conform — a  gradual  forcible  reduction  of  deformity.  According 
to  Ridlon  and  Jones,  the  flexed  limb  is  often  forced  to  conform  to  the 
straight  brace  by  a  temporary  exaggeration  of  the  lumbar  lordosis 
which  lessens  as  the  muscular  spasm  subsides  under  treatment. 

The  treatment  is  divided  by  Mr.  Thomas  into  stages : 

1.  A  preliminary  stage  of  rest  in  bed  for  the  reduction  of  deformity 
and  to  aUow  for  subsidence  of  acute  symptoms. 

2.  The  patient  is  then  allowed  to  go  about  on  crutches  wearing  an 
iron  patten  at  least  four  inches  in  height  under  the  sound  foot 
(Fig.  281). 

3.  When  all  symptoms  of  disease  have  subsided  and  when  atrophy 
of  the  muscles  is  marked  the  brace  may  be  removed  at  night. 

4.  The  brace  is  finally  discarded,  but  the  patten  and  crutches  are 
still  used  in  walking. 

The  records  of  Mr.  Thomas  show  the  average  time  of  confinement 
to  the  bed  to  be  twenty-two  weeks,  and  the  average  duration  of 
treatment  twenty-one  months. 


358 


TUBERCULOUS  DISEASE  OF   THE  HIP- JOINT 


It  is  stated  by  Ridlon^  that  in  actual  practice  these  principles  were 
not  carried  out,  for  nearly  all  the  children  treated  under  Thomas' 
direction  at  the  time  his  observations  were  made  were  walking  about 


Fig.  281. — Thomas  splint  applied  -nath  patten  and  crutches. 


Fig.  282. — A  form  of  Thomas  brace  employed  in  the  treatment  of  infants.  The 
pelvic  band  assures  better  fixation.  The  screws  at  the  lower  extremity  are  arranged 
to  permit  the  addition  of  a  foot-piece  for  traction. 

without  the  high  patten  and  crutches,  even  before  the  deformity 
had  been  overcome  and  while  muscular  spasm  and  pain  persisted. 

1  A  report  of  Sixty-two  Cases  of  Hip  Disease  Observed  in  the  Practice  of  Hugh 
Owen  Thomas,  New  York  Med.  Jour.,  October  4,  1890. 


TREATMENT  359 

This  was,  however,  probably  an  exigency  of  practice  among  the 
poor,  and  at  all  events  it  is  in  line  with  Thomas'  contention  that 
pressure  and  concussion  are  less  harmful  than  friction. 

Modifications  of  the  Thomas  Brace. — Although  not  so  stated  in  his 
book,  Thomas  used  at  times  a  short  brace  extending  only  to  the 
lower  part  of  the  thigh,  thus  permitting  motion  at  the  knee.  This 
was  apparently  designed  as  a  convalescent  splint,  although  its  use 
was  not  restricted  to  that  class  of  cases.  In  certain  cases  a  strip  of 
iron,  "the  nurse,"  was  screwed  to  the  lower  extremity  of  the  long 
brace,  prolonging  it  beyond  the  foot  in  order  to  prevent  the  patient 
from  bearing  weight  upon  the  limb. 

The  Thomas  brace,  so  effective  in  preventing  and  overcoming 
flexion  deformity,  does  not  prevent  lateral  distortion.  In  fact,  in 
24  of  the  58  patients  examined  by  Ridlon,^  adduction  was  present; 
a  larger  proportion,  it  would  appear,  than  would  be  found  in  a  like 
number  of  cases  under  treatment  with  the  traction  brace.  This 
tendency  to  lateral  distortion  may  be  guarded  against  by  placing  a 
half-band  of  material  similar  to  the  chest  band  about  the  side  of  the 
pelvis;  on  the  same  side  for  adduction,  on  the  opposite  side  for 
abduction  of  the  limb. 

The  Thomas  brace  has  a  great  advantage  over  other  appliances  in 
its  simplicity.  It  can  be  made  by  a  blacksmith,  but  it  must  be  fitted 
by  the  surgeon.  This  fitting  requires  great  care.  In  the  words  of 
Mr.  Thomas:  "The  fitting  although  sometimes  successful  in  one 
visit,  may  at  other  times  occupy  many  days.  The  surgeon  should 
mould,  by  reducing  or  increasing  the  various  curves,  until  the  instru- 
ment ceases  to  tend  to  rotate,  and  at  none  of  its  angles  irritates  the 
patient."  He  concludes,  in  a  general  answer  to  the  criticisms  that 
have  always  been  made  on  the  difficulty  of  adjustment  of  the  appli- 
ance, as  follows:  "What  I  can  invariably  do  must  be  possible  to 
others." 

Treatment  by  Plaster  Supports. — The  treatment  of  hip  disease  in 
the  more  important  clinics  in  this  country  has  greatly  changed  in 
recent  years,  and  fixation  of  the  diseased  joint  in  the  position  most 
favorable  for  recovery  with  limited  function  is  now  generally  recog- 
nized as  the  most  important  element  of  mechanical  treatment. 

The  period  of  complete  inactivity  is  shortened  and  weight-bearing 
is  permitted  when  it  causes  no  discomfort,  in  order  to  avoid  the 
atrophy,  loss  of  growth  and  muscular  and  ligamentous  relaxation 
that  may  follow  complete  and  prolonged  disuse  of  the  limb. 

The  routine  of  treatment  as  applied  in  hospital  service  may  be 
outlined  as  follows : 

Deformity,  if  present,  is  at  once  reduced  under  anesthesia  by  trac- 
tion and  gentle  leverage,  and  the  limb  is  placed  in  full  extension,  20 
degrees  of  abduction,  and  fixed  by  a  long  spica.     If  the  disease  is  of 

1  Loc.  cit. 


360  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


Fig.  284 


Tiu.  285 
Figs.  283,  284  and  285. — Different  forms  of  plaster  supports  used  in  the  treatment 

of  hip  disease. 


TREATMENT  361 

a  more  acute  type  traction  plasters  are  applied  to  the  limb  and  a 
spica  plaster  support,  reaching  from  the  ankle  to  the  mammary  line, 
carefully  moulded  about  the  pelvis  and  hip,  is  adjusted.  The 
patient  is  then  placed  in  bed  with  a  traction  weight  of  ten  pounds  or 
more.  This  treatment  is  continued  until  all  acute  symptoms  have 
subsided,  a  wheeled  couch  on  which  the  patient  lies  taking  the  place 
of  the  bed  during  the  day.  The  immediate  correction  of  deformity 
followed  by  fixation  in  the  desired  attitude  has  a  manifest  advantage 
over  the  tedious  reduction  by  traction  which  necessitates  long  con- 
finement to  the  bed  with  no  compensatory  advantages  except  the 
avoidance  of  a  so-called  operation  (Fig.  293). 

After  several  weeks  or  months,  weight -bearing  is  tested  and  if  it 
causes  no  immediate  or  subsequent  discomfort  it  is  permitted.  If 
the  joint  is  sensitive  to  weight-bearing,  although  it  causes  no  actual 
pain,  axillary  crutches  or  a  perineal  splint  may  be  used  for  a  time. 


Fig.  286. — The  short  plaster  spica,  combined  with  traction  used  after  reduction 

deformity. 

As  soon  as  the  indications  permit,  the  long  spica  is  replaced  by  the 
Lorenz  plaster  support,  permitting  motion  at  the  knee  and  in  the 
lumbar  spine,  but  supporting  the  joint  by  accurate  adjustment  to 
the  pelvis.  With  this  appliance  a  certain  degree  of  flexion  of  the 
limb  cannot  be  prevented,  nor  is  it  within  limits  undesirable  when 
weight-bearing  is  permitted,  as  it  lessens  the  direct  jar  on  the  joint. 
With  care  the  attitude  of  abduction  may  be  assured  during  the 
entire  course  of  treatment.  This  is  of  the  greatest  importance,  for 
when  the  head  of  the  femur  lies  deep  in  the  acetabulum  direct  pres- 
sure is  removed  from  its  upper  part  and  the  corresponding  surface 
of  the  acetabulum,  the  points  which  most  often  present  evidence 
of  pressure  erosion. 

If  the  patient  is  seen  early  before  deformity  has  appeared  the  short 
spica  is  applied  without  preliminary  traction  and  locomotion  is 
permitted  if  the  symptoms  indicate  that  the  joint  will  tolerate  it. 

This  treatment  in  which  the  degree  of  protection  is  adapted  to 


362  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

the  character  of  the  disease  differs  from  that  of  Lorenz,  which  is 
practically  a  routine  ambulatory  treatment  by  the  short  spica,  as 
decidedly  as  from  the  routine  treatment  by  braces. 

The  principles  are  those  that  govern  the  treatment  of  tuber- 
culous disease  of  the  lungs,  periods  of  rest  alternating  with  an 
activity  regulated  by  the  sjTuptoms.     It  is  a  compromise  between 


Fig.  287. — The  long  plaster  spica  bandage.     The  dotted  line  indicates  the  position 

of  the  steel  support. 

the  treatment  of  the  local  disease  and  the  effect  of  this  treatment 
upon  the  lunb  and  upon  the  patient.  Thus,  acute  symptoms  at  any 
stage  of  the  disease  indicate  rest  in  bed,  the  long  spica  and  traction, 
discomfort,  a  lessened  activity  and  relief  from  weight- bearing.  If, 
however,  the  local  disease  is  quiescent,  weight-bearing  without 
motion  improves  the  nutrition  of  the  limb  and  that  of  the  body  in 
general. 


TREATMENT  363 

Application  of  Plaster  Splints. — The  long  spica  is  often 
applied  in  out-patient  practice.  It  is  a  better  protection  than  the 
less  comprehensive  forms  in  that  it  prevents  movements  of  the  leg, 
diminishes  the  jar  on  a  sensitive  joint  and  enclosing  the  foot  lessens 


Fig.  288. — The  Schultze  pelvic  support  for  the  application  of  the  plaster  spica. 

the  danger  of  edema  in  the  extremity.     If,  however,  the  disease  is 

acute  rest  in  bed  with  traction  in  the  manner  described  is  indicated. 

A  plaster  splint  to  assure  support  should  fit  perfectly,  consequently 

it  should  be  applied  with  as  little  padding  as  is  practicable.     A 


Fig.  289. — Box  with  adjustable  saural  auyport  of  Lhu  Loruiiz  inudul  used  for  the 
application  of  the  plaster  spica. 

covering  of  shirting,  such  as  is  used  in  the  application  of  the  plaster 
jacket,  is  fitted  to  the  body  and  the  limb  reinforced  with  one  or 
more  layers  of  cotton  flannel  bandage,  those  parts  that  are  likely 
to  be  subjected  to  pressure — the  toes,  the  heel,  the  malleoli,  the 


364 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


condyles  of  the  femur,  the  sides  of  the  pelvis,  the  anterosiiperior 
spines,  and  the  thorax — being  further  protected  by  cotton  wadding 
or  other  material.  The  plaster  bandage  should  cover  the  lower  half 
of  the  thorax,  and  it  should  extend  to  the  ends  of  the  toes.  It 
should  be  applied  under  slight  traction,  very  carefully  around  the 
adductor  region  and  reinforced  beneath  the  buttock,  which  should 
be  entirely  covered  and  supported.  iVt  this  point,  in  the  line  in 
which  the  bar  of  the  Thomas  hip  splint,  a  strip  of  malleable  steel, 
long  enough  to  reach  from  the  middle  of  the  trunk  to  the  lower  third 
of  the  thigh  may  be  incorporated  in  the  plaster  for  greater  security 
(Fig.  287).     The  plaster  splint  is  reinforced  in  front  of  the  hip  and 


Fig.  290. — A  pelvic  support  in  use.     The    patient    presents    fixed  flexion    to    1.35 
degrees,  and  fixed  adduction  of  35  degrees. 

beneath  the  knee,  the  points  at  which  the  support  is  likely  to  break 
before  it  becomes  firm.  The  proper  anteroposterior  support  of  the 
buttock,  consequently  of  the  hip-joint,  which  is  of  the  first  impor- 
tance, is  almost  invariably  neglected  in  the  ordinary  application. 
The  spica  may  be  applied  in  the  upright  posture  by  means  of  the 
swing,  as  used  in  the  application  of  the  plaster  jacket,  the  weight 
being  supported  in  part  by  the  sound  leg  while  the  other  is  pendent. 
Usually  it  is  applied  with  the  patient  in  the  reclining  posture,  the 
body  lying  on  a  shoulder  rest,  and  a  sacral  support.  The  arms 
are  then  drawn  above  the  head  to  increase  the  capacity  of  the  thorax, 
while  the  limbs  are  supported  by  an  assistant  (Fig.  290). 


TREATMENT  365 

In  the  more  recent  cases  deformity  may  be  practically  reduced 
at  the  second  application  of  the  bandage,  because  of  the  relaxa- 
tion of  the  spasm  assured  by  the  rest  and  fixation;  thus  it  is  par- 
ticularly useful  in  the  treatment  of  young  children  in  the  outdoor 
practice,  for  whom  hospital  care  would  otherwise  be  required. 


Fig.  291. — The  short  spica  of  the  Lorenz  Fig.  292. — Rear  view  of  the  short 

type  showing  the  adjustment  to  the  pelvis.  spica. 

The  Short  or  Lorenz  Spica. — ^The  short  spica  is  used  as  routine 
treatment  of  hip  disease  in  Lorenz's  clinic  in  Vienna  and  in  a  some- 
what modified  form  this  principle  of  treatment  has  been  accepted 
in  many  of  the  clinics  in  this  country,  the  aim  being  to  fix  the  afl'ected 
limb  in  an  attitude  of  slight  flexion  and  abduction,  the  primary 
attitude  of  hip  disease,  by  accurate  adjustment  to  the  pelvis  and  at 
the  same  time  permitting  movement  in  the  lumbar  spine  and  at  the 
knee.     A  close-fitting  covering  of  shirting  is  drawn  over  the  limb 


366  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

and  pelvis,  and  a  wide  friction  bandage  is  then  introduced  between 
the  skin  and  shirting  to  serve  as  a  ''scratcher."  The  bony  promi- 
nences are  suitably  protected  in  the  manner  described,  and  the 
bandages  are  then  applied,  being  drawn  closely,  and  carefully 
moulded  about  the  pelvis  and  thigh,  so  that  movement  in  the  joint 
may  be  controlled.  The  upper  and  lower  extremities  of  the  ban- 
dage are  cut  away  as  Illustrated  (Fig.  291),  and  the  shirting  is  then 
drawn  over  the  margins  of  the  plaster  and  sewed.  This  makes  a 
smooth  covering  and  holds  the  padding  in  position.     If  the  bandage 


Tig.  293. — The  spiea  with  traction  and  the  wheeled  couch  used  at  the  Hospital  for 
Ruptured  and  Crippled. 

is  extended  below  the  knee  it  is  more  efficient  in  checking  the  action 
of  the  long  muscles  which  are  attached  to  the  pelvis  and  to  the  leg. 
It  should  be  stated  that  in  the  treatment  of  some  of  the  more  acute 
cases  by  Lorenz  the  weight  of  the  body  is  removed  by  a  prolongation 
or  stirrup  of  sheet  steel  which  projects  beyond  the  foot,  the  two 
extremities  being  incorporated  in  either  side  of  the  plaster  bandage 
in  the  neighborhood  of  the  knee  (Fig.  296).  In  the  better  class  of 
cases  a  leather  support  provided  with  a  steel  foot-plate  extending 
slightly  below  the  foot  and  a  joint  at  the  knee  is  used  in  German 
clinics.     The  short  spica  bandage  in  combination  with  the  traction 


TREATMENT  367 

hip  brace  (Fig.  298)  answers  the  same  purpose  and  is  more  efficient 
if  somewhat  more  cumbersome. 

The  importance  of  the  attitude  of  abduction  as  a  means  of  reheving 
pressure  and  preventing  deformity  has  been  mentioned.     To  assure 


Fig.  294. — The  Lorenz  spica,  showing  the  adjustment  to  the  pelvis.  In  this  case 
it  is  extended  below  the  knee,  but  in  many  instances  motion  at  the  knee-joint  is 
permitted. 


this  position  in  ambulatory  treatment  the  lateral  elevations  of  the 
spica  should  overlap  the  short  ribs  and  if  necessary  a  perineal  band 
may  be  used  as  illustrated  in  the  figure  (Fig.  294).  A  cork  sole  of 
about  an  inch  in  thickness  may  be  used  on  the  abducted  side  to 
prevent  tilting  of  the  pelvis. 


368 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 


Fig.  295. — The  Lorenz  spica  with 
the  perineal  band.  A  shoe  with  a  cork 
sole  should  be  worn  on  the  abducted 
side. 


The  ad^'alltages  of  immediate 
correction  of  deformity  under 
anesthesia  have  been  mentioned. 
It  should  not  be  employed  if  the 
deformity  is  of  long  standing  and 
if  the  disease  is  active  or  of  the 
destructive  type  accompanied  by 
infiltration  of  the  tissues  or  by  a 
discharging  sinus.  In  such  cases 
traction  is  to  be  preferred  and  in 
certain  instances  in  which  be- 
cause of  general  shortening  of  the 


Fig.  296. — The  Lorenz  stilt,  some- 
times used  in  the  treatment  of  the  more 
painful  cases.  This  is  incorporated  in 
the  plaster  bandage  above  the  knee  and 
it   extends   below  the  foot. 


Fig.  297. — The  short  spica  bandage  reaching  to  the  knee  in  combination  with  the 
long  traction  brace.  One  perineal  band  has  been  removed  in  order  to  show  how  the 
joint  is  supported  by  the  bandage. 


TREATMENT 


309 


contracted  tissues  and  subluxation  of  the  femur,  reduction  by  this 
method  is  impracticable,  correction  should  be  deferred  until  the 
process  of  repair  is  practically  completed. 

The  impression  that  one  might  receive  from  descriptions  of  the 
treatment  of  hip  di.sease  is  that  most  cases  begin  acutely,  or  that 


Fig.  298. — ^The  Lorenz  spica  combined  with  the  traction  hip  brace,  sometimes 
used  when  the  diseased  joint  will  not  permit  weight-bearing.  The  perineal  strap 
prevents  displacement  of  the  plaster  appliance. 

when  the  patients  are  brought  for  treatment  the  disease  is  in  an 
acute  stage,  or  that  deformity  is  present,  so  that  preliminary  recum- 
bency is  required.  In  a  large  proportion  of  the  cases,  however,  the 
symptoms  a  re  not  acute,  nor  is  deformity  present.  In  such  instances 
the  hip  spliat  or  plaster  spica  may  be  applied  without  preliminary 
recumbency ,  and  if  the  joint  is  fixed  in  the  normal  attitude  and 
protected  a  relatively  rapid  recovery  without  deformity  and  with 
a  fair  range  of  motion  may  be  hoped  for. 
24 


370  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

Review  of  the  Mechanical  Treatment. — Traction  is  the  most 
efficient  means  of  assuring  rest  of  a  diseased  joint  if  the  patient  is 
recumbent  or  if  the  Hmb  is  pendant.  Under  careful  and  constant 
supervision  some  traction  may  be  exerted  by  an  ambulatory  splint, 
but  under  ordinary  conditions  the  traction  hip  brace  is  only  efficient 
as  a  stilt  in  relieving  the  pressure  and  shock  of  weight-bearing. 
It  does  not  prevent  motion  at  the  joint  nor  does  the  traction  prevent 
friction. 


Fig.  299. — Lateral  view.     The  shape  of  the  pelvic  band_is  like  that  illustrated  in 

Fig.  301. 

The  most  accurate  statistics  of  final  results  in  cases  treated  by 
this  apparatus  illustrate  also  its  ineffectiveness  in  preventing  deform- 
ity. Thus  in  a  total  of  35  cases  treated  at  the  New  York  Orthopedic 
Dispensary^  practical  anchylosis  was  present  in  74  per  cent,  and  in 
60  per  cent,  the  limb  was  distorted  to  a  greater  or  less  degree. 

1  Shaffer  and  Lovett:  New  York  Med.  Jour.,  March  2,  1878. 


REVIEW  OF   THE  MECHANICAL   TREATMENT 


371 


The  Bradford  brace,  if  properly  adjusted,  holds  the  limb  in  abduc- 
tion and  indirectly  splints  the  joint.  It  is  therefore  the  most 
efficient  of  the  short  traction  braces. 

The  long  traction  brace  adds  the  element  of  splinting  in  which 
the  short  braces  are  deficient  and  it  is  therefore  far  more  satisfactory 
in  the  treatment  of  the  acute  or 
de^^tructive  types  of  cases. 

The  Thomas  brace  is  an  efficient 
splint  and  fixes  the  joint  more  per- 
fectly than  other  braces,  but  it  does 
not  hold  the  limb  in  the  abducted 
attitude  or  even  prevent  adduction. 

Plaster  supports  enable  one  to 
dispense  with  the  services  of  a 
mechanic,  a  great  advantage  in 
many  instances.  The  long  spica 
with  traction  in  recumbency  is  the 
most  satisfactory  treatment  for 
acute  disease.  The  long  spica  in- 
cluding the  foot  is  of  service  in  the 
treatment  of  young  children  in  out- 
patient practice. 

The  short  spica  is  efficient  in 
selected  cases  in  proportion  to  the 
accuracy  of  its  adjustment. 

The  vexed  question  is  that  of 
early  weight-bearing,  as  opposed 
to  complete  cessation  of  function, 
from  the  inception  to  the  end  of 
the  disease,  a  period  of  several  years. 

From  the  practical  stand-point, 
what  has  been  described  as  the 
treatment  by  plaster  supports  is  far 
more  satisfactory  both  to  patient 
and  surgeon  than  the  old  routine 
treatment  by  the  traction  brace. 
A  comparison  of  final  results 
is,  however,  impracticable.  It  is 
claimed  that  splinting  and  weight- 
bearing  will  favor  anchylosis.  If 
the  surfaces  of  the  femur  and  of 
the    acetabulum    are    denuded   of 

cartilage  and  are  held  in  apposition,  the  process  of  repair  should 
cause  adhesion,  fixation  and  cure,  as  contrasted  with  deformity  and 
subluxation,  which  would  separate  the  mutually  'diseased  surfaces. 
Under  such  conditions  anchylosis,  which  is  the  best  assurance  of 
cure  and  future  comfort  is  an  end  to  be  desired  rather  than  avoided. 


Fig.  300.— The  Taylor  hip  splint 
as  used  by  Taylor  in  the  later  years 
of  his  practice  with  but  one  perineal 
band.  The  illustration  shows  also  an 
appliance  for  preventing  or  for  cor- 
recting slight  degrees  of  adduction, 
while  the  brace  is  in  use  as  a' walking 
appliance.  The  abduction  bar  is 
buckled  about  the  upper  extremity  of 
the  other  thigh.  (H.  L.  Taylor, 
Medical  News,   March  23,    1889.) 


372 


TUBERCULOUS  DISEASE  OF   THE  HIP- JOINT 


Loss  of  motion  is,  moreover,  very  common  in  cases  treated  by  con- 
trasting methods.  For  example,  in  a  series  of  cases  illustrating 
final  results  treated  exclusively  by  the  traction  hip  splint,  there  was 
practical  fixation  in  74  per  cent.^  It  may  be  assumed  also  that 
efficient  splinting  of  the  joint  with  the  limb  in  an  attitude  of 
selection,  combined  with  modified  weight-bearing,  is  more  likely 


Fig.  301. — Taylor's  median  abduction  brace  as  a  bed  splint  to  overcome  adduction 
by  counter-pressure  upon  the  sound  side. 

to  check  the  destructive  changes  in  the  joint  than  is  stilting  with 
inefficient  splinting.     As  a  matter  of  personal  experience  it  may  be 


1  Log.  cit. 


TREATMENT  DURING  STAGE  OF  RECOVERY 


373 


stated  that  some  of  the  most  disastrous  results  from  the  functional 
stand-point  have  followed  the  most  careful  treatment  by  the  traction 

brace,   due  to  complete  disuse 
through  a  period  of  years. 

Weight-bearing  should  not  be 
permitted  if  it  causes  discom- 
fort, or  if  abscess  is  present,  or 
if  the  disease  is  of  a  destructive 
type.  In  such  cases  the  long 
traction  brace  is  the  most  satis- 
factory appliance.  The  best 
treatment  is  that  which  is 
adapted  to  the  patient's  sur- 
roundings  and  to    his    general 


Fig.  302. — Modified  brace  to  be  worn 
during  convalescence.  Same  patient  as 
in  Fig.  274.  The  thoracic  part  has  been 
removed  and  the  lower  end  of  the  stem 
has  been  made  into  a  caliper,  passing 
through  the  heel  of  the  shoe.  The  stem  is 
extended  by  means  of  the  key  until  the 
heel  is  lifted  slightly  from  the  shoe;  thus 
the  hip  is  relieved  from  shock. 


^ 


Fig.  303. — Judson's  perineal  crutch. 
This  support  suspended  from  the 
shoulders  may  be  employed  as  a  sub- 
stitute for  axillary  crutches.  It  is  also 
used  as  a  convalescent  splint  in  the 
treatment  of  hip  disease. 


and  local  condition,  a  treatment  therefore  of  selection  as  opposed  to 
one  of  routine. 

Treatment  during  Stage  of   Recovery. — It    is  much  easier  to 
assure  one's  self  that  the  disease  is  still  active  than  to  decide  when 


374 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


it  is  ciu-ed.  For  the  sjTiiptoms  may  have  been  quiescent  for  months 
or  years  even,  under  the  protective  treatment,  and  yet  they  may 
recur  on  the  shghtest  provocation  when  this  treatment  has  been 
discontinued. 

To  judge  of  the  probable  duration  of  the  disease  in  a  given  case, 
one  must  consider  its  area,  its  quaHty,  and  its  comphcations.  If, 
for  example,  the  primary  sjTuptoms  indi- 
cate that  the  focus  of  infection  is  of  lim- 
ited area  and  is  contained  within  the 
bone,  rapid  recovery  possibly  in  a  year, 
may  be  expected;  but  in  the  ordinary 
tjTDC  of  disease  in  which  the  joint  has 
been  invaded,  repair  can  hardly  be  an- 
ticipated in  less  than  three  or  four  years. 
If  sufficient  time  has  elapsed  to  permit 
of  natm^al  cure,  if  there  have  been  no 
sjTuptoms  of  active  disease  for  a  year  or 
more,  and  if  the  x-ray  picture  is  satis- 
factory it  may  be  assumed  that  conval- 
escence  is   established.    If  a  brace  has 


Fig.  304  Fig.  305 

Figs.  304  and  305. — Convalescent  hip  splint,  allowing  motion  at  the  knee.     (Taj-lor.) 

been  employed  it  may  be  modified  to  serve  as  a  protection  by 
attaching  it  to  the  shoe  so  adjusted  as  to  be  slightly  longer  than 
the  limb,  in  order  that  du-ect  concussion  and  pressure  may  be  less- 
ened (Fig.  302).  Or  a  brace  jointed  at  the  knee,  after  the  Taylor 
pattern,  may  be  employed. 

This  brace  is  so  adjusted  as  to  be  slightly  longer  than  the  limb,  so 
that  the  heel  does  not  touch  the  bottom  of  the  shoe  (Fig.  305). 


TREATMENT  DURING  STAGE  OF  RECOVERY 


375 


Thus  the  weight  is  in  great  part  supported  on  the  perineal  band. 
The  weight  of  the  brace  may  be  in  part  supported  and  incidentally 
slight  traction  may  be  exerted  by  adhesive  plaster  applied  above  the 
knee  (Fig.  306).  The  foot-plate,  to  which  the  upright  is  attached, 
is  shown  in  Figs.  305  and  307. 


Fig.  306  Fig.  307 

Figs.  306  and  307.— Details  of  the  Taylor 
convalescent  hip  brace.  Fig.  306,  the  ad- 
hesive plaster.  Fig.  307,  the  foot-plate  show- 
ing the  method  of  attachment. 


Fig.  308 
Fig.  308.— The    action    of    the 
Taylor  convalescent  hip  brace  in 
removing     direct     pressure     illus- 
trated by  wooden  model. 


As  the  strain  upon  the  part  is  increased,  one  watches  carefully 
for  the  return  of  muscular  spasm  or  for  restriction  of  the  range  of 
motion.  If  the  range  of  motion  does  not  diminish,  and  if  the  deform- 
ity that  may  be  present  does  not  increase  or  does  not  appear  if  it 
were  absent,  the  brace  may  be  removed  at  intervals  and  finally 
discarded. 


376  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

As  has  been  stated,  the  short  spica  after  the  Lorenz  model  is  an 
admirable  support  during  the  period  of  recovery.  It  checks  motion 
at  the  joint,  yet  it  permits  the  function  of  support,  and  thus  a  grad- 
ual rebuilding  of  the  bony  structure  which  has  become  atrophied 
during  the  course  of  the  disease.  By  means  of  this  appliance  the 
limb  may  be  held  in  the  desired  position  of  moderate  abduction,  and 
it  is  particularly  effective  when  the  limb,  because  of  destructive 
changes  in  the  joint,  is  inclined  toward  adduction. 

The  period  of  supervision  even  in  favorable  cases  should  be  pro- 
tracted, for  no  patient  can  be  considered  free  from  the  danger  of 
relapse  for  a  long  time  after  apparent  cure.     If  there  is  firm  bony 


Fig.  309. — Double  hip  disease,  terminating  in  bonj^  anchylosis. 

union,  as  in  exceptional  cases,  ciu"e  is  assured;  but  if  there  is  simple 
fibrous  anchylosis,  and  particularly  if  there  is  upward  displacement 
of  the  trochanter,  there  is  a  strong  tendenc}^  toward  flexion  and 
adduction,  even  though  the  disease  is  cm-ed.  This  tendency  should 
be  resisted  by  persistent  "stretching"  in  the  dhections  of  abduction 
and  extension  and  if  necessary  apparatus  must  be  again  applied  to 
reduce  the  deformity  or  to  hold  the  limb  in  proper  position  until 
stability  is  assured.  When  the  brace  or  plaster  has  been  discarded, 
the  patient  should  be  trained  to  walk  with  equal  steps,  placing  the 
limb,  as  far  as  possible,  on  an  equality  with  its  fellow  and  adapting 
in  like  manner  the  stronger  to  the  weaker  member. 


BILATERAL  HIP  DISEASE 


377 


This  has  an  important  influence  in  checking  the  tendency  to 
deformity  and  in  modifying  or  even  conceahng  the  limp,  a  point  to 
which  Judson  has  repeatedly  called  attention. 


Fig.  310. — Hyperextension  at  the  knee  following  disease  of  the  hip-joint  and  its 
treatment  by  the  traction  brace. 

Bilateral  Hip  Disease. — Ninety-five  cases  of  bilateral  hip  disease 
were  treated  in  the  Hospital  for  Ruptured  and  Crippled  during  a 
period  of  ten  years. 


Fig.  311. — Left  hip  disease,  showing  swelling  caused  by  abscess,  also  the  absence 

of  flexion  deformity. 

As  a  rule  the  second  hip  is  affected  some  time  after  the  symptoms 
of  disease  of  the  first  have  been  apparent,  but  occasionally  both 


378 


TUBERCULOUS  DISEASE  OF   THE  HlP-JOlNT 


joints  are  involved  simultaneously.  In  most  instances  the  symp- 
toms are  rather  subacute,  owing,  very  likely,  to  the  fact  that  the 
activity  of  the  patient  is  so  restricted. 

Treatment. — The  treatment  is  similar  in  principle  to  that  of  the 
unilateral  form.     The  patient  during  the  greater  part  of  the  course 

of  the  disease  must  be  confined  in 
the  recumbent  position,  although 
not  necessarily  in  bed.  The  double 
Thomas  hip  splint  or  spica  plaster 
support  may  be  used.  If  the  dis- 
ease is  acute,  traction  is  added  in 
the  manner  already  described.  If 
the  disease  of  one  hip  is  acute  and 
is  attended  by  abscess  formation, 
excision  for  the  purpose  of  lessen- 
ing the  strain  upon  the  patient 
may  be  advisable. 

If  motion  is  greatly  restricted 
in  both  joints  locomotion,  unless 
crutches  are  used,  is  very  difficult, 
as  motion  at  the  knees  can  supply 
only  in  small  part  the  function  of 
the  hip-joints.  In  such  instances 
excision  of  one  hip  with  the  aim 
of  obtaining  a  certain  amount  of 
motion  may  be  considered. 

Hip  Disease  Combined  with  Dis- 
ease of  Other  Parts. — The  most 
common  combination  is  with  Pott's 
disease.  The  two  processes  may 
be  distinct,  but  occasionally  it 
would  appear  that  the  disease  of 
the  hip  is  caused  by  the  infection 
of  an  abscess,  which,  coming  from 
the  spine,  remains  for  a  long  time 
in  contact  with  the  capsule  of  the 
joint.  In  5  of  130  cases  of  disease 
of  the  hip-joint  of  which  the  final 
results  were  reported  by  Gibney, 
^Yaterman,  and  Reynolds  (page 
396),  Pott's  disease  was  a  compli- 
cation, in  2  instances  preceding  and  in  3  following  the  disease  at 
the  hip.  The  combinaton  of  the  two  diseases  makes  the  mechanical 
treatment  difficult.  Recumbency  ofters  the  best  opportunity  for  the 
eftective  adjustment  of  apparatus  when  the  disease  of  either  part  is 
acute.  At  a  later  period  crutches  may  be  employed,  together  with 
the  necessarv  braces. 


Fig.  312. — Untreated  hip  disease. 
Slight  flexion  and  adduction  (apparent 
shortening).  The  scar  of  a  former  ab- 
scess is  seen  on  the  outer  aspect  of  the 
thigh. 


ABSCESS  COMPLICATING  HIP  DISEASE  379 

Hip  Disease  in  Infancy. — Hip  disease  in  infancy  is  far  less  com- 
mon than  in  early  childhood.  It  presents  nothing  of  special  interest 
except  that  its  effect  upon  the  function  of  the  joint  and  upon  the 
development  of  the  limb  is  usually  more  marked  than  in  older  sub- 
jects. Tuberculous  disease  of  this  joint  must  be  differentiated  from 
infectious  epiphysitis,  in  which  prompt  operative  treatment  is 
indicated.  *  A  modified  Thomas  brace  is  most  efficient  in  treatment 
(Fig.  282). 

Hip  Disease  in  the  Adult. — Hip  disease  in  the  adult  may  present 
the  typical  symptoms  of  the  ordinary  form,  but  it  is  usually  of  the 
more  subacute  type.  Not  infrequently  it  is  a  complication  of  tuber- 
culosis of  the  lungs. 

The  subacute  form  of  tuberculous  disease  is  often  difficult  to  dis- 
tinguish from  arthritis  deformans,  if  this  is  limited  to  the  hip-joint. 
The  mechanical  treatment  is  not  difficult,  but  early  excision  or 
arthrotomy  to  induce  anchylosis  may  be  advisable  to  hasten  the 
cure  of  the  disease.  This  is  far  more  important  than  in  childhood, 
because  few  adults  can  afford  the  time  required  for  the  natural 
cure,  and  because  in  many  instances  the  general  condition  of  the 
patient  may  demand  relief  from  the  depressing  affects  of  the  local 
disease,  especially  if  it  be  complicated  by  suppuration. 

Abscess  Complicating  Hip  Disease. — It  may  be  assumed  that  a 
limited  collection  of  the  fluid  products  of  the  tuberculous  process  is 
present  in  nearly  every  case  of  hip  disease  in  which  the  joint  surfaces 
are  actually  involved.  In  many  instances  it  remains  within  the 
joint.  In  a  larger  proportion  of  the  cases  the  capsule  is  perforated, 
the  fluid  escapes,  and,  if  the  quantity  is  sufficient  to  form  an  appre- 
ciable tumor,  it  is  classed  as  an  abscess.  Such  abscesses  may  be 
detected  in  about  50  per  cent,  of  the  cases  that  are  treated  under 
ordinary  conditions. 

In  1472  final  results  collected  from  various  sources  the  percent- 
age of  abscess  was  as  appears  in  the  following  table : 


39  cases  reported  by  Shaffer  and  LovettV   . 
82  cases  reported  by  Gibney^       .... 
390  cases  reported  by  Bruns,^  Tubingen 
568  cases  reported  by  Konig,*  Gottingen 
125  cases  reported  by  Sasse,^  Berlin  . 
82  cases  reported  by  Prendlsburger,^  Vienna 
98  cases  reported  by  Bradford,^  Boston 
84  cases  in  private  practice,  C.  F.  Taylor^ 
552  cases  from  Lorenz  clinic 


69.0  per  cent. 

60.0 

58.3 

56.6 

50.0 

51.0 

37.0 

25.0 

47.0 


1  New  York  Med.  Jour.,  May  21,  1887. 

2  New  York  Med.  Rec,  March  2,  1878. 

3  Beitr.  z.  klin.  Chir.,  1895,  xxx. 

^  Die  Spec.  Tuberculose  der  Knoch  u.  Gelenke,  Berlin,  1902. 
5  Arbeit  aus  der  Chir.  klin.  der  K.  Univ.  Berlin  (Bergmann's  clinic),  1896. 
^  Behand.  der  Gelenktuberculose  und  ihre  Endresultate  aus  der  klinik  Albert, 
Wien,  1894. 

'  Am.  Jour.  Med.  Sc,  December,  1908. 

8  Boston  Med.  and  Surg.  Jour.  March  6,  1879. 


380 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 


Most  often  the  abscess  first  appears  upon  the  anterior  and  upper 
part  of  the  thigh,  in  the  space  betv\'een  the  sartorius  and  tensor 
vaginae  femoris  muscles.  In  other  instances  it  may  be  detected 
first  on  the  inner  side  of  the  thigh,  or  it  may  form  a  tumor  beneath 
the  ghiteal  muscles,  its  situation  being  influenced  by  the  point  at 
which  the  capsule  is  ruptured. 

In  rare  instances  the  acetabulum  may  be  perforated  and  a  pelvic 
abscess  may  be  formed,  or  the  pus  may  find  its  Avay  into  the  pelvis 
along  the  iliopsoas  muscle;  and  occasionally  a  pelvic  abscess  may 
exist  "^'hich  appears  to  have  no  direct  communication  with  the  joint. 

The  weakest  point  of  the  capsule  is  in  the  anterior  wall,  where  it 
is  covered  by  the  iliopsoas  muscle  and  by  its  bursa,  which  often 
communicate  with  the  joint.  A  second  weak  place  is  in  the  posterior 
wall. 

In  a  total  of  321  abscesses  in  hip  disease  recorded  by  Konig^  the 
situation  was  as  follows: 

On  the  inner  side  (inside  the  femoral  artery) 26 

Front  of  the  joint  (between  arterj-  and  anterosuperior  spine)   .       .       .  126 

Region  of  the  trochanter 63 

Posterior  surface [49 

In  the  pehis 41 

In  other  situations 16 


Fig.  313.- 


-  Abscess  in  hip  disease.    The  brace  is  pro\-ided  with  the  Thomas  ring,  and 
with  the  ratchet  extension. 


The  tuberculous  abscess  is  a  s\'mptom  and  common  accompani- 
ment of  hip  disease,  which,  in  cases  treated  under  proper  conditions, 
is  not  of  great  importance;  and  yet,  on  the  other  hand,  it  is  recog- 
nized as  a  dangerous  complication.  It  is  dangerous  to  life  because 
of  the  profuse  suppiuation  that  may  follow  infection,  and  to  func- 
tion because  of  the  adhesions  and  contractions  that  may  result. 
This  is  evident  in  all  statistics.  It  is  clearly  shown  in  those  of 
Bruns.  In  this  list  the  mortality  in  the  non-suppurative  cases  was 
23  per  cent.,  and  of  the  suppurative  52  per  cent. 

1  Loc.  cit. 


ABSCESS  COMPLICATING  HIP  DISEASE  381 

Significance. — If  abscess  appears  early  in  the  course  of  the  dis- 
ease, it  usually  indicates  that  it  is  of  a  destructive  character,  and  that 
the  interior  of  the  joint  is  involved;  therefore  function  is  less  likely 
to  be  preserved  than  in  those  cases  in  which  the  disease  has  been 
confined  to  the  interior  of  the  bone. 

Abscess  formation  is  often  preceded  by  pain,  by  an  increase 
of  muscular  spasm  and  consequent  distortion,  and  often  by  an 
elevation  of  temperature.  These  acute  symptoms  subside  and  a 
fluctuating  swelling  appears.  It  may  be  inferred  that  the  pain  in 
such  a  case  was  due  to  the  tension  of  the  abscess  within  the  capsule, 
and  that  the  relief  of  pain  followed  perforation  and  the  escape  of 
the  fluid. 

In  perhaps  the  larger  proportion  of  cases,  more  especially  those 
in  which  the  joint  has  been  protected,  the  appearance  of  the  abscess 
is  not  preceded  by  acute  symptoms,  such  as  have  been  described. 
Its  appearance  is  long  delayed,  and  but  for  the  swelling  its  presence 
would  not  be  suspected. 

As  the  progress  of  the  disease  is  influenced  by  the  strain  and  injury 
to  which  the  part  is  subjected,  so  abscess,  a  symptom  of  disease,  is 
more  common  in  those  cases  in  which  early  and  efficient  treatment 
has  been  neglected;  for  the  same  reason  its  subsequent  course  is 
directly  influenced  by  the  protection  that  the  diseased  joint  receives. 

The  danger  from  abscess  is  infection.  Occasionally  the  abscess 
may  become  infected  before  an  opening  forms.  Such  infection  may 
be  inferred  when  the  overlying  tissues  are  hot  and  sensitive,  and 
when  fever  is  present;  but,  as  a  rule,  the  abscess  is  sterile  until  the 
skin  is  perforated.  If  the  abscess  sac  is  small  and  if  drainage  is 
efficient,  and  especially  if  communication  with  the  joint  has  been 
occluded,  infection  is  of  slight  consequence.  But  if  before  the 
opening  has  formed  the  abscess  has  perforated  intermuscular  fasciae 
and  has  extended  between  the  layers  of  muscles  in  various  direc- 
tions, infection  is  likely  to  cause  severe  local  and  constitutional 
symptoms.  The  thigh  becomes  the  seat  of  an  infectious  cellulitis, 
pockets  of  pus  form,  which  cannot  be  properly  drained;  hectic, 
emaciation,  and  loss  of  appetite  follow,  and  if  the  profuse  discharge 
of  pus  persists  myeloid  degeneration  of  the  internal  organs  may  result. 
Such  patients  are  said  to  die  of  exhaustion,  but  the  cause  of  exhaus- 
tion is  an  infected  abscess. 

Treatment. — Admitting  that  abscess  is  a  sjTQptom  whose  impor- 
tance stands  in  direct  relation  to  the  care  that  has  been  exercised  in 
the  treatment  of  the  disease,  and  that  in  the  better  class  of  cases  the 
danger  from  this  source  is  slight,  still  it  is  also  true  that  abscess  is 
the  chief  danger  in  hip  disease.  One's  views  as  to  the  treatment 
are  likely  to  be  influenced  by  the  class  of  cases  with  which  he  is  most 
familiar.  Some  surgeons  have  advocated  absolute  non-interference 
with  the  symptomatic  abscess  on  the  ground  that  in  many  instances 
it  finally  disappears  by  spontaneous  absorption,  or  that  the  com- 


382  TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 

munication  with  the  joint  may  close,  so  that  the  danger  of  infection 
after  an  opening  has  formed  is  shght.  Finally,  that  the  results 
after  non-interference  are  better  than  those  reported  after  operative 
treatment.  Others  insist  that  all  collections  of  fluid  of  this  char- 
acter should  be  drained  as  soon  as  they  are  discovered,  because  of 
the  danger  of  infection  before  an  opening  forms  and  because  of  the 
advantage  gained  by  preventing  burrowing  of  pus.  Little  could  be 
said  against  this  latter  course  were  it  not  that  infection  is  as  common 
after  operative  treatment  as  when  a  spontaneous  opening  forms; 
the  only  advantage  in  favor  of  the  artificial  opening  being  that  the 
cavity  with  which  it  communicates  should  be  smaller  and  more 
direct  than  when  the  fluid  has  undermined  the  tissues  in  various 
directions,  but  this  is  offset  by  the  fact  that  at  least  20  per  cent,  of 
abscesses  disappear  without  treatment.  In  fact,  as  compared  with 
indiscriminate  incisions,  the  let-alone  treatment  should  be  preferred 
when  proper  after-treatment  cannot  be  assm'ed. 

It  would  appear,  however,  that  the  middle  course,  between  the 
extremes,  is  the  safest,  and  especially  so,  as  by  far  the  larger  number 
of  patients  must  be  treated  under  conditions  that  do  not  permit  of 
proper  care.  At  the  Hospital  for  Ruptiu-ed  and  Crippled  abscesses 
are  treated  s^Tuptomatically.  If  a  swelling  appears  but  remains 
quiescent  and  causes  no  s^Tuptoms  it  is  not  distiu-bed.  If  it  enlarges, 
the  tension  of  the  fluid  is  relieved  by  asphation,  which  maybe 
repeated  as  required,  compression,  after  the  evacuation  of  the  fluid, 
being  applied  by  means  of  a  pad  and  bandage.  If  the  contents  are 
of  such  a  nature  that  aspiration  is  unsatisfactory,  a  small  incision 
is  made,  the  contents  are  expressed  and  the  opening  is  immediately 
closed  with  sutures.  This  procedure  by  which  infection  is  avoided 
may  be  repeated  at  intervals.  It  may  be  employed  also  when  deep- 
seated  abscess  within  the  joint  causes  painful  tension. 

If  the  abscess  is  of  large  size,  or  if  acute  s^inptoms  are  present, 
the  child  is  admitted  to  the  hospital.  Here  the  same  general 
principle  is  followed,  but  in  certain  instances  it  may  be  thought 
advisable  to  explore  the  joint  in  addition  to  opening  the  abscess. 
In  such  cases  the  incision  must  be  longer,  the  wound  is  then  closed 
with  superficial  and  deep  sutures,  and  a  firm  dressing  is  applied. 
This  operation,  if  performed  under  aseptic  precautions,  causes  no 
disturbance,  and  it  removes  necrotic  material  which  must  be  an 
obstacle  to  spontaneous  absorption.  In  many  instances  the  abscess 
is  permanently  cured,  although  if  the  condition  that  induced  it 
remains  unchanged  fluid  will  again  accumulate,  and  if  so  a  spon- 
taneous opening  will  form  in  the  line  of  the  incision.  This  opera- 
tion is  not  a  radical  cure  of  the  abscess  or  of  the  disease;  it  is  simply 
a  means  of  thorough  evacuation  for  the  purpose  primarily  of  accom- 
plishing what  the  aspirator  does  only  in  part.  If  the  abscess  has 
become  infected  its  contents  are  completely  remo^■ed,  the  wound  is 
then  packed  with  gauze,  and  provision  is  made  for  efficient  drainage. 


EXPLORATORY  OPERATIONS  383 

In  the  treatment  of  abscesses  the  injection  of  iodoform  emulsion, 
in  connection  with  the  aspiration  or  incision,  has  been  thoroughly 
tested.  The  results,  as  far  as  the  disappearance  of  the  abscess  was 
concerned,  were  not  as  good  as  from  simple  aspiration;  and  as  the 
procedure,  being  somewhat  of  the  nature  of  an  operation,  caused 
the  patients  some  discomfort  and  anxiety,  it  was  discontinued. 
From  the  clinical  stand-point  there  is  little  evidence  that  these  injec- 
tions exercise  any  particular  influence  upon  the  disease,  but,  theoreti- 
cally, iodoform  should  lessen  the  infectiousness  of  the  tuberculous 
fluid,  and  by  local  irritation  stimulate  the  growth  of  granulation 
tissue.     (See  Calot's  Injections.) 

Sinuses. — Treatment. — When  the  disease  is  active  the  sinuses 
that  serve  as  drains  should  not  be  disturbed.  And  in  the  advanced 
cases  when  disease  is  quiescent  and  when  the  tissues  about  the  joint 
are  of  the  peculiar,  resistant,  "porky"  consistency,  active  measures, 
either  for  the  purpose  of  closing  sinuses  or  for  the  correction  of 
deformity,  should  be  deferred.  In  many  instances,  however, 
sinuses  persist  as  tuberculous  fistulse,  serving  no  useful  purpose. 
In  this  class  the  complete  removal  of  the  infected  tissue  by  excision 
or  by  thorough  curetting  is  the  most  effective  remedy.  The  various 
applications  of  pure  carbolic  acid,  solution  of  salicylic  acid,  iodoform 
emulsion,  balsam  of  Peru,  and  the  like  are  of  some  service. "  The 
most  satisfactory  supplemental  treatment  of  this  class  is  Beck's 
mixture.  Sufficient  is  injected  to  completely  fill  the  sinus  which  if 
it  is  no  longer  necessary  as  a  drain  often  closes,  the  mixture  being 
gradually  absorbed,  otherwise  the  injected  material  is  extruded. 

Exploratory  Operations. — In  certain  instances  exploratory  opera- 
tions may  be  indicated.  If,  for  example,  pain  and  swelling  indicate 
tension  within  the  capsule  it  may  be  relieved  by  a  small  direct 
incision  or  the  joint  may  be  explored  with  the  possibility  of  finding 
a  localized  focus  of  disease  that  may  be  removed. 

The  joint  may  be  opened  by  an  anterolateral  incision,  beginning 
one  inch  to  the  outer  side  of  the  antero  superior  spine  and  extend- 
ing downward  about  three  inches.  This  exposes  the  line  of  junc- 
tion between  the  tensor  vaginse  femoris  and  the  gluteus  medius 
muscles.  When  these  are  separated  from  one  another  the  anterior 
surface  of  the  capsule  of  the  joint  is  laid  bare.  If  more  room  is 
required  the  tensor  vaginse  femoris  muscle  may  be  divided.  The 
capsule  is  then  incised  in  the  line  of  the  neck  and  through  the  incision 
the  head  of  the  bone  may  be  extruded  by  rotating  the  limb  outward 
and  extending  it.  By  this  means  the  character  of  the  disease  may 
be  ascertained  and  in  certain  instances  localized  foci  in  the  neck  or 
in  the  head  of  the  bone  may  be  removed.  If  the  operation  is  under- 
taken primarily  for  the  removal  of  disease  localized  in  the  neck,  the 
incision  (Fig.  314),  with  the  division  and  upward  displacement  of 
the  trochanter  gives  better  access  to  the  joint.  The  wound  is  then 
closed  or  drained  as  may  seem  advisable.     By  such  intervention 


384  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

the   course  of  the  disease  may  be  shortened  in  some  instances, 
although  cure  by  this  means  is  unusuah 

Temporary  anterior  dislocation  of  the  head  of  the  femur  by 
means  of  the  anterolateral  incision  may  be  of  value  in  acute  and 
painful  disease.  Since  the  s^Tiiptoms  are  usually  relieved  by  sponta- 
neous displacement.  Posterior  dislocation  for  this  purpose  has  been 
performed  by  Bradford  in  several  cases  with  satisfactory  results,  the 
bone  being  again  replaced  when  the  disease  had  become  quiescent.^ 
The  object  of  this  operation  is  to  remove  the  apposing  bones  from 
direct  contact,  and  to  relieve  the  muscular  spasm  that  accompanies 
acute  disease. 

Exploratory  operations  may  be  of  special  value  in  the  later  stages 
of  the  disease,  to  ascertain  the  cause  of  long-continued  suppuration, 
or  of  abnormal  delay  in  repair,  which  may  be  due  to  detached  or 
adherent  fragments  of  necrosed  bone  within  the  joint.  This  point 
is  illustrated  by  the  statistics  of  61  cases  of  hip  disease  treated  by 
excision  by  Poor.-  In  15  of  these  loose  bone  was  found  in  the  joint, 
and  in  7  the  head  of  the  bone  was  detached. 

In  98  cases  investigated  by  Lehman^  at  the  Wurzburg  clinic 
sequestra  were  present  in  20.4  per  cent.,  and  in  70  per  cent,  of  88 
cases  treated  by  Riedel.^ 

An  exploration  of  the  joint  by  one  familiar  with  surgical  technic 
should  be  free  from  danger,  and  it  may  be  of  much  value.  Direct 
removal  of  the  disease  by  tunneling  through  the  trochanter  has 
been  advocated  by  Huntington.  This  might  be  successful  if  the 
focus  were  confined  to  the  neck  and  were  clearly  defined  in  the  .r-ray 
picture,  but  such  cases  are  very  exceptional. 

Excision  of  the  Hip. — ^The  operation  of  excision  is  now  classed 
as  a  treatment  of  necessity  in  certain  cases,  usually  those  in  which 
recovery  under  conservative  treatment  is  considered  very  doubtful. 
For  example,  when  there  is  progressive  failure  in  health;  when  it  is 
impossible  to  drain  the  joint  effectively  after  infection;  when  there 
is  evidence  of  extension  of  the  disease  to  the  shaft  of  the  femur  or  to 
the  pelvic  cavity,  or  when  other  serious  complications  exist. 

In  certain  instances  the  excision  may  follow  an  exploratory  opera- 
tion; in  such  cases  the  anterolateral  incision  may  be  employed  and 
the  neck  and  head  of  the  bone  only  may  be  removed.  In  this 
operation  the  diseased  tissue  is  removed  as  thoroughly  as  possible 
with  the  sharp  spoon,  by  scrubbing  with  iodoformized  gauze,  and 
by  flushing  with  hot  water.  If  the  joint  is  not  infected  it  is  dried; 
iodoform  emulsion  may  be  injected  or  the  pure  carbolic  acid  may  be 
applied,  and  the  various  tissues  are  then  sewed  in  layers;  pressure 
is  applied,  the  aini  being  to  secure  immediate  union.  If  this  does 
not  take  place  drainage  is  employed  in  the  usual  manner. 

1  Tr.  Am.  Orthop.  Assn.,  xiii.  -  Xew  York  Med.  Jour.,  April  23,  1892. 

^  Inaug.  Diss.  Wilrzbiirg,  1896. 

^Centralbl.  f.  Chir.,  1893,  xx,  Nos.  7  and  8. 


EXCISION  OF  THE  HIP 


385 


In  typical  cases  the  operation  is  performed  because  of  extensive 
disease  and  infected  abscess,  and  in  such  instances  usually  the  entire 
upper  extremity  of  the  bone  to  the  trochanter  minor  is  removed. 

A  satisfactory  method  is  that  of  Konig. 

An  incision  about  five  inches  in  length  is  made  in  a  line  joining 
the  trochanter  and  the  postero-inferior  spine  of  the  ilium.  About 
two-thirds  of  the  length  is  above  and  one-third  over  the  trochanter. 
The  incision  is  deepened  to  expose  the  capsule  and  the  surface  of  the 
trochanter,  from  which  one  removes  the  insertion  of  the  gluteus 
maximus  and  the  tendons  of  the  medius  and  minimus.  The  muscles 
are  separated  in  the  line  of  the  incision  and  the  capsule  is  widely 
opened.  With  a  thick,  strong  knife  he  detaches  all  the  muscular 
attachments  to  the  anterior  margin  of  the  trochanter,  while  the 


Fig.  314. — Rydygier's  incision  for  excision  of  the  hip. 


limb  is  rotated  outward,  removing,  if  possible,  a  thin  section  of 
periosteum  and  bone.  The  same  process  is  then  repeated  on  the 
posterior  surface,  the  limb  being  rotated  inward.  The  trochanter 
is  then  removed. 

The  acetabular  insertion  of  the  capsule,  together  with  the  adjoin- 
ing upper  border  of  the  acetabulum,  is  then  cut  away  and  the  neck 
of  the  femur  is  separated  from  the  shaft  with  a  saw  or  chisel.  All 
the  diseased  parts  are  then  removed,  including  the  acetabular  wall 
and  adjoining  bone,  if  necessary.  The  wound  is  partly  closed  with 
drainage,  and  the  extremity  of  the  femur  is  placed  within  the  ace- 
tabulum, where  it  should  be  retained  for  a  time  by  a  plaster  bandage 
or  Thomas  brace  provided  with  traction  straps.  When  the  patient 
begins  to  walk  a  hip  splint  or  other  support  is  used  for  a  time  to 
prevent  deformity.  One  of  the  most  efficient  supports  of  this  class 
25 


386  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

is  the  short  spica,  the  Hmb  being  fixed  in  an  attitude  of  overextension 
and  moderate  abduction  for  many  months  with  the  aim  of  obtaining 
bony  or  fibrous  anchylosis. 

Another  form  of  incision  is  that  of  Rydygier/  shown  in  the  accom- 
panying ilhistration.  The  flap  is  lifted,  the  trochanter  major  is  cut 
through  and  with  its  attached  muscles  turned  upward.  The  capsule 
is  then  opened  and  the  femur  is  dislocated  for  inspection.  All  the 
diseased  parts,  including  the  entire  acetabulum,  if  necessary,  to- 
gether with  the  capsule,  are  then  removed.  Complete  removal  of 
the  acetabulum  is  indicated  when  it  is  perforated,  a  procedure  par- 
ticularly advocated  by  Bardenheuer. 

The  success  or  failure  of  excision  of  the  hip  as  a  life-saving  opera- 
tion, provided  the  diseased  bone  has  been  removed,  is  determined  by 
the  after-treatment,  and  in  this  drainage  is  the  first  essential.  The 
opening  must  be  large  and  the  shaft  of  the  bone  must  be  drawn  down 
by  efficient  traction,  so  that  it  may  not  obstruct  the  opening,  and  the 
exuberant  granulations  must  be  removed  from  time  to  time.  Short 
glass  drainage  tubes  of  diameter  up  to  one  and  one-half  inches  as 
suggested  by  Phelps  may  be  used  with  advantage.  Through  such 
a  tube  or  speculum  the  gauze  is  inserted,  the  opening  permitting 
inspection. 

The  importance  of  an  open-air  life  (the  sun  treatment)  after 
these  operations  can  hardly  be  exaggerated.  The  lack  of  this,  the 
inefficiency  of  the  after-treatment  in  seciu-ing  proper  drainage,  and 
the  postponement  of  the  operation  until  amyloid  changes  are 
advanced  explain  the  unsatisfactory  character  of  the  results. 

The  functional  results  after  excision  in  this  class  of  cases  are  not  as- 
good  as  those  that  may  be  obtained  when  the  operation  has  been  per- 
formed at  an  earlier  period.  If  motion  is  retained  there  is  usually 
a  corresponding  weakness  of  weight-bearing  function.  In  many 
instances  there  is  upward  displacement  of  the  shaft  of  the  femur 
upon  the  ilium  with  consequeM  flexion  and  adduction  deformity, 
while  in  a  third  class  of  cases  a  movable  joint  of  sufl&cient  strength 
may  be  preserved.  The  ultimate  shortening  is  considerably  greater 
than  after  conservative  treatment.  This  is  accounted  for  by  the 
upward  displacement  of  the  femur  and  by  the  removal  of  the  two 
epiphyses  of  its  upper  extremity. 

In  a  period  of  twelve  years,  1888  to  1899  inclusive,  149  operations 
of  excision  were  performed  at  the  Hospital  for  Ruptured  and 
Crippled.  Dm-ing  this  time  1283  cases  of  hip  disease  were  treated 
in  the  wards  and  1870  new  cases  were  recorded  in  the  out-patient 
department.  Thus  the  operation  was  performed  in  11.6  per  cent, 
of  those  in  the  hospital,  but  the  relative  frequency  of  the  operation 
in  the  enthe  number  of  patients  under  treatment  was  considerably 
less  than  this. 

1  Mosetig-Moorhof:  Wien.  klin.  Wchnschr.,    1905,  No.  20,  '   ^ 


EXCISION  OF   THE  HIP  387 

One  hundred  and  twenty-one  of  these  operations  of  excision, 
those  performed  prior  to  1897,  have  been  carefully  analyzed  by 
Townsend.^  The  121  operations  were  performed  on  119  patients, 
in  2  instances  both  hips  having  been  operated  upon.  In  113 
abscesses  or  sinuses  were  present,  in  most  instances  infected.  In  5 
cases  there  was  disease  of  the  spine  as  well  as  the  hip;  in  2  instances 
of  the  knee;  in  2  of  the  tarsus;  in  3  of  the  ilium.  In  24  the  anterior 
incision  was  employed,  in  97  the  posterior.  In  18  instances  the 
acetabulum  was  seriously  diseased,  and  in  10  the  shaft  of  the  femur 
was  involved.  This  indicates  the  character  of  the  disease  in  the 
cases  operated  upon. 

In  99  of  the  119  cases  the  later  results  of  the  operation  were  ascer- 
tained. Of  these  52  were  dead  and  47  were  living.  Of  the  52 
deaths  9  were  due  directly  to  the  operation,  "shock;"  28  were 
caused  by  exhaustion  (persistent  suppuration);  9  by  tuberculous 
meningitis;  7  by  other  causes.  Thirty-seven  deaths  occurred 
within  six  months  and  10  others  within  one  year  of  the  operation. 
Of  the  47  patients  living  at  the  time  of  the  investigation,  26  were 
cured.  Of  the  remaining  number  about  one-half  were  in  poor  con- 
dition, so  that  recovery  could  not  be  expected.  It  is  evident  that 
in  a  large  proportion  of  the  cases  the  operation  was  unsuccessful 
as  a  life-saving  measure,  since  suppuration  persisted.  The  func- 
tional results  in  these  cases  are  shown  in  the  table  on  the  following 
page. 

Lovett^  has  reported  the  results  of  50  excisions  in  a  similar  class 
of  cases  at  the  Boston  Children's  Hospital,  1877  to  1895.  The 
-  number  of  patients  actually  treated  in  the  wards  of  the  hospital  is 
not  stated,  but  1 100  cases  were  recorded  as  having  been  under  treat- 
ment during  this  time,  a  percentage  of  excisions  of  4.5  of  the  total 
number.  In  8  of  the  cases  osteomyelitis  of  the  femur  was  present, 
and  in  15  the  acetabulum  was  perforated.  The  ultimate  mortality 
was  about  50  per  cent. 

Poor^  has  reported  the  results  in  65  cases  operated  upon  at  St. 
Mary's  Hospital,  New  York,  with  a  final  mortality  of  about  34  per 
cent.  In  21  cases  osteomyelitis  of  the  shaft  of  the  femur  was  pres- 
ent. In  11  cases  there  was  perforation  of  the  acetabulum,  and  in 
9  of  these  the  opening  communicated  with  an  intra-pelvic  abscess. 

These  statistics  are  quoted  to  illustrate  the  relative  efficiency  of 
late  excision.  The  extent  of  the  lesions  in  some  of  the  cases  shows 
that  recovery  would  have  been  impossible  without  operation,  and 
its  failure  to  relieve  the  symptoms  in  so  many  instances  is  sufficient 
evidence  that  it  was  postponed  too  long  or  that  it  was  not  sufficiently 
radical.  Under  proper  conditions  for  treatment  excision  of  the  hip 
is  almost  never  required,  but  in  hospital  practice  it  should  be  per- 
formed oftener  and  earlier  in  the  course  of  the  disease. 

1  Med.  News,  June  26,  1897.  -  Tr.  Am.  Orthop.  Assn.,  x. 

3  New  York  Med.  Jour.,  April  23,  1892. 


388 


TUBERCULOUS  DISEASE  OF   THE  HIP-JOIXT 


Table  Showixg  Shortening,  Motion,  Number  of  Sinuses  Present,  and  Angle 
OF  Greatest  Extension  in  Forty-seven  Cases  of  Excision. 

(TOWNSEND.) 


No. 

Time  since 

General 

Sinuses 

Angle  of      ' 
greatest 
extension. 

Motion  in 

Shortening 

operation. 

condition. 

present. 

degrees. 

in  inches. 

1 

6  J  years 

Good 

3 

150 

0 

2i 

2 

6i       " 

Fair 

1 

135 

0 

4 

3 

6 

Good 

0 

180 

100 

3 

4 

5i      " 

" 

0 

180 

35 

3 

5 

51      " 

Fair 

0 

145 

10 

4 

6 

5i       " 

Good 

1 

165 

0 

li 

7 

5 

" 

0 

155 

5 

2i 

8 

4f       " 

If 

3 

160 

0 

21 

9 

44      " 

" 

0 

160 

0       ! 

2j 

10 

4i       " 

" 

0 

165 

0 

li 

11 

4 

K 

0 

150 

0 

li 

12 

4 

Poor 

4 

0 

1* 

13 

31      " 

Good 

0 

155 

0 

li 

14 

3i      " 

" 

0 

160 

30 

1 

15 

3 

Poor 

1 

165 

0 

3 

4 

16 

2 

Fair 

2 

145 

30 

4 

17 

2 

Good 

18 

2 

Fair 

1 

170 

0 

h 

19 

2 

Good 

0 

150 

0 

3 

20 

li     " 

" 

0 

175 

2 

21 

li     " 

" 

0 

165 

30 

i 

22 

1*     " 

" 

0 

150 

0 

1 

23 

li     " 

« 

0 

150 

0 

u 

24 

li     " 

c< 

1 

180 

0 

i 

25 

li     " 

Fair 

6 

175 

15 

1 

26 

1 

Poor 

2 

165 

0 

21 

27 

1 

Good 

0 

170 

0 

u 

28 

1 

" 

0 

155 

0 

1 

29 

1 

" 

0 

175 

0 

4 

30 

1 

Poor 

0 

180 

10 

li 

31 

11    months 

" 

3 

170 

0 

4 

32 

10 

" 

0 

180 

40 

li 

33 

,     10 

Good 

3 

165 

0 

i 

34 

10 

" 

0 

160 

0 

2 

35 

10 

" 

1 

165 

0 

1 

36 

10 

Poor 

1 

160 

0 

4 

37 

10 

Good 

3 

155 

10 

li 

38 

9 

" 

1 

0 

1 

39 

9 

" 

0 

2 

40 

9 

Poor 

1 

170 

0 

2 

41 

9 

Fair 

3 

1 

42 

8 

Good 

0 

180 

130 

i 

43 

8 

" 

0 

ISO 

1 

4 

44 

8 

Poor 

1 

165 

10 

3 

4 

45 

7 

" 

46 

7 

Good 

0 

ISO 

10 

li 

47 

7 

t         a 

0 

160 

1            '' 

1 
4 

Amputation. — Amputation  at  the  hip  should  follow  excision  if 
suppuration  persists  and  if  the  condition  of  the  patient  does  not 
improve,  provided  the  internal  organs  are  not  hopelessly  diseased. 
The  operation  of  amputation  after  complete  excision  is  a  simple 
procedure  and  it  should  not  be  attended  with  great  danger. 


CORRECTION  OF  DEFORMITY 


389 


Correction  of  Deformity. — The  various  methods  of  correcting 
deformity  during  the  active  stages  of  the  disease  have  been  described, 
and  the  importance  of  preventing  deformity  throughout  the  entire 
course  of  treatment  has  been  emphasized.  At  the  present  time,  for 
one  reason  or  another,  deformity  from  this  cause  is  very  common, 
either  because  its  importance  is  not  appreciated  or  because  it  is  con- 
sidered as  a  necessary  concomitant  of  the  disease,  treated  by  appara- 
tus, as  it  is  in  the  natural  cure.  At  all  events,  in  many  instances  it 
is  allowed  to  persist  until  the  accommodative  changes  about  the 
diseased  jeint  have  fixed  the  limb  in  the  deformed  position. 


Fig.  315.- 


-Extreme  deformity  after  hip  disease,  showing  the  attitude  before  opera- 
tion.    (See  Figs.  316  and  317.) 


■  In  this  class  of  cases,  in  which  the  muscles  are  structurally  short- 
ened and  in  part  transformed  to  fibrous  tissue,  and  in  which  the 
anterior  wall  of  the  capsule  has  become  retracted  and  adherent  to 
the  surrounding  parts,  forcible  reduction  under  anesthesia,  or  oste- 
otomy, may  be  required.  If  the  disease  is  quiescent  or  cured,  if  the 
head  of  the  femur  or  what  remains  of  it  is  in  the  normal  position, 
and  if  a  fair  range  of  motion  remains,  forcible  reduction  after  division 


390 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


of  the  bands  of  fascia  or  the  muscles  that  hold  the  limb  in  the 
deformed  position  is  advisable. 


Fig.  316. — The  favorite  attitude  in  recumbency.      (See  Fig.  315.) 

In  cases  in  which  the  head  of  the  bone 
is  destroyed,  motion  persisting  (patho- 
logical excision),  the  aim  should  be  to 
secure  an  anterior  transposition  of  the 
upper  extremity  of  the  femur,  and  to  at- 
tain this  result  one  proceeds  as  in  reduc- 
ing or  transposing  the  congenitally  dis- 
placed hip — by  longitudinal  traction,  by 
forcible  abduction,  combined  with  massage 
of  the  adductors,  and,  finally,  by  gradual 
extension — preceded  usually  by  division 
of  the  resistant  parts  about  the  anterior 
superior  spine.  The  limb  is  then  fixed 
by  a  plaster  spica  in  an  attitude  of 
moderate  abduction  and  overextension. 
Later  the  abduction  is  lessened,  but  the 
overextended  position  is  maintained  for 
many  months,  and  is  assm'ed  by  passive 
mo^"ements  after  the  support  is  removed. 
Forcible  reduction  in  cured  or  quiescent 
cases  is  practically  free  from  danger. 

Femoral  Osteotomy. — If  the  deformity 
is  fixed  by  bony  anchylosis  or  by  firm, 
fibrous  adhesions  within  the  joint;  or  if 
it  is  feared  that  violence  may  stimulate 
dormant  disease;  or  if  there  is  such  a  de- 
gree of  upward  displacement  of  the  femur 
upon  the  pelvis  that  the  deformity  is 
likely  to  recur  after  replacement,  it  is 
Fig.    317. After    correc-     better  to   correct   the  deformity  by   an 

tion    by   osteotomy    and    di-      OStCOtomV  of  the  femur. 

Sr  (Git^TTsef f£:        The  patient,  having  been  prepared  for 

315  and  316.)  Operation,  is  turned  upon  the  side  and  a 


-  CORRECTION  OF  DEFORMITY 


391 


sand-bag  is  placed  between  the  thighs.  A  small  osteotome, 
about  the  shape  of  a  lead-pencil,  of  which  one  extremity  is 
flattened  to  a  cutting  edge  (Vance's  instrument),  is  pushed 
directly  through  the  soft  parts  to  the  femur  at  a  point  about  two 
inches  below  the  apex  of  the  trochanter.  It  is  turned  until  its 
cutting  edge  is  at  a  right  angle  to  the  shaft  and  it  is  then  driven 
through  the  cortical  substance  of  the  bone.  When  it  has  penetrated 
at  one  point  it  is  withdrawn,  and  adjoining  portions  are  cut  until 
about  half  the  circumference  is  divided,  when  with  slight  force  the 
bone  may  be  fractured.  If  the  deformity  is  of  long  standing, 
division  oT  the  contracted  tissues  in  the  adductor  region  and  below 
the  anterosuperior  spine  may  be  required. 


Fig.  318. — The  correction  of  adduction  deformity  by  cuneiform  osteotomy. 


The  limb  is  then  fixed  in  complete  extension  and  moderate 
abduction  by  a  long  plaster  spica  bandage,  which  should  remain 
in  position  for  several  months,  although  the  patient  may  be  allowed 
to  bear  weight  on  the  limb  a  few  weeks  after  the  operation.  The  long 
spica  may  be  replaced  by  the  short  one  at  the  end  of  two  months. 
The  latter  or  some  similar  appliance  should  be  used  until  tests  show 
that  there  is  no  longer  danger  of  recurrence  of  the  deformity. 

The  advantages  of  the  subcutaneous  method  are  simplicity  and 


392  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

freedom  from  danger.  No  dressings  are  required,  except  a  pad  of 
gauze  over  the  minute  opening.  If  there  is  anchylosis  between  the 
femur  and  the  pelvis  no  support  will  be  required  after  the  bone  has 
united,  but  if  there  is  motion  in  the  joint  some  fixative  appliance 
should  be  employed  for  a  time  to  prevent  recurrence  of  a  part  of  the 
deformity.  In  cases  in  which  motion  is  preserved,  and  yet  because 
of  depression  or  shortenmg  of  the  femoral  neck  abduction  is 
checked  by  contact  of  the  trochanter  with  the  pelvis  cuneiform, 
osteotomy  as  described  in  the  treatment  of  coxa  vara  should  be 
performed  (Fig.  318). 

Prognosis. — Mortality. — The  direct  mortality  of  hip  disease  is 
due  almost  entu-ely  to  the  immediate  or  remote  effects  of  abscess. 
This  is  illustrated  by  the  statistics  of  Bruns,  in  which  the  mortality 
from  all  causes  of  the  non-suppurative  cases  was  23  per  cent.,  as 
compared  with  52  per  cent,  in  those  in  whom  suppuration  was 
present. 

The  mortality  among  the  patients  treated  at  many  of  the  German 
clinics  is  much  higher  than  in  the  corresponding  class  in  this 
country. 

At  Tubingen,  according  to  "Wagner,^  it  was  40  per  cent. 

At  Kiel,  according  to  ^Nlimimelthy,  it  was  48.59  per  cent,  in  non- 
operative  cases  and  53.96  per  cent,  in  operative  cases. 

At  Marburg,  according  to  ^Nlarsch,  it  was  35  per  cent,  in  non- 
operative  cases  and  40.4  per  cent,  in  operative  cases. 

At  Heidelberg,  according  to  Huismans,-  it  was  46.6  per  cent,  in 
non-operative  cases  and  58  per  cent,  in  operative  cases. 

At  Zurich,  according  to  Pedolin,^  it  was  37.7  per  cent,  in  non- 
operative  cases  and  54  per  cent,  m  operative  cases. 

At  Vienna,  according  to  Prendlsburger,^  it  was  17  per  cent,  in 
all  cases. 

In  552  cases  from  Lorenz'  clinic  it  was  18  per  cent. 

At  Gottingen,  according  to  Ivonig,^  40.3  per  cent. 

Dollinger''  estimates  the  mortality  from  all  causes  m  German 
clinics  as  48.8  per  cent.     In  non-suppurative  cases  as  16.5  per  cent. 

In  a  total  of  636  cases  treated  by  conservative  methods  by  Rabl, 
1859  to  1894,  definite  results  were  ascertained  in  519;'^  335  were 
hospital  cases.  Of  these  216  were  cured  (64.4  per  cent.),  70  died 
(20.8  per  cent.)  and  49  (14.4  per  cent.)  were  still  under  treatment; 
184  were  treated  as  out-patients.  Of  these,  132  were  cured  (71.5 
per  cent.),  35  died  (19.2  per  cent.)  and  17  (9.2  per  cent.)  remained 
under  treatment. 

1  Beitr.  z.  klin.  Chir.,  1895,  xiii. 

2  Quoted  by  Binder:  Ztschr.  f.  orthop.  Chir.,  1SS9,  Band  vii,  Heft  2  and  3. 

3  Centralbl.  f.  Chir.,  July  25,  lS96,^'o.  30.  ^  Loc.  cit. 

5  Konig:  Das  Hoeftgelenk,  Berlin,  1902. 

6  Handb.  d.  orthop.  Chir.,  1906. 

■■  Zur  Conserv.  Behand.  der  tuberculosen  Knochen  und  Gelenksleiden,  J.  Raljl, 
Leipzig  und  Wien,  1S95. 


PROGNOSIS  393 

Menard^  in  a  series  of  1321  cases  treated  under  favorable  condi- 
tions estimates  the  mortality  at  7  per  cent. 

In  288  cases  treated  at  the  Hospital  for  Ruptured  and  Crippled 
New  York,  reported  by  Gibney/  the  death-rate  was  12.5  per  cent. 

In  93  final  results  of  cases  treated  at  the  Boston  Children's  Hos- 
pital there  were  6  deaths,  6.4  per  cent.^ 

In  private  practice  the  statistical  reports  of  final  results  show  the 
death-rate  to  be  extremely  small.  C.  F.  Taylor,^  94  cases,  including 
24  in  which  suppuration  was  present,  3  deaths.  L.  A.  Sayre,^  212 
cases,  5  deaths.     Lorenz,^  60  cases,  with  3  deaths. 

In  the  clinics  of  this  country  the  death-rate  has  been  estimated  to 
be  from  10  to  15  per  cent.,  a  rate  of  mortality  much  lower  than  that 
reported  from  those  abroad.  This  is  accounted  for  in  part  by  the 
fact  that  patients  are  of  a  better  class  and  in  part  because  they  receive 
earlier  and  more  efficient  mechanical  protection. 

The  causes  of  death,  according  to  Wagner's  statistics  of  124  cases, 
were  as  follows: 

Hip  disease 35 

General  tuberculosis        ..." 37 

Tuberculous  meningitis 13 

Tuberculosis  of  the  lungs 11 

Acute  miliary  tuberculosis 5 

Amyloid  degeneration 8 

Septic  infection 12 

Intercurrent  disease 3 

124 

Thirty  per  cent,  of  the  deaths  occurred  in  the  first  year  of  the 
disease,  26  per  cent,  in  the  second  year,  and  20.4  per  cent,  in  the 
third  year. 

The  percentage  of  recovery  was  65  per  cent,  of  those  in  the  first 
decade  of  life,  56  per  cent,  of  those  in  the  second,  and  but  28  per 
cent,  of  those  in  the  third  decade. 

The  causes  of  death  in  50  cases  among  778  patients  treated  at 
the  New  York  Orthopedic  Dispensary  and  Hospital  during  the 
years  1877  to  1882  were:^ 

Tuberculous  meningitis 20 

Amyloid  degeneration 5 

Exhaustion 3 

Tuberculosis  of  the  lungs 3 

Tuberculous  peritonitis 1 

Septicemia 1 

Convulsions 1 

Unknown           16 


50 


1  Etude  sur  Coxalgie,  1907. 

2  New  York  Med.  Jour.,  July  and  August,  1877. 

3  Bradford:  Loc.  cit. 

*  Boston  Med.   and  Surg.   Jour.,   March  6,   187'9. 

6  New  York   Med.   Jour.,   April  30,    1892. 

6  Wien.  Klinik,  1892,  10  and  11. 

'  Shaffer  and  Lovett:  New  York  Med.  Jour.,  May  21,  1887. 


394  TUBERCULOUS  DISEASE  OF   THE  HIP-JOINT 

Of  96  deaths  recorded  at  the  Alexandra  Hospital,  London  (a 
mortality  of  about  26  per  cent,  of  the  cases  treated),  the  causes 
were : 

Tuberculous  meningitis 16.1   per  cent. 

Albuminuria  and  dropsy 20 . 8  " 

Tuberculosis  of  the  lungs 8.3  " 

Exhaustion 9.4  " 

Erysipelas  and  pyemia 3.1  " 

After  operation 9.4  " 

Intercurrent  diseases 7.3  " 

Unknown 25.0 


99.4 


The  direct  mortality  of  hip  disease  should  include  all  deaths  due 
to  operation,  those  caused  by  exliaustion,  and  amyloid  degenera- 
tion which  is  almost  always  the  result  of  profuse  suppuration  second- 
ary to  pyogenic  infection  Tuberculous  meningitis,  a  common  and 
apparently  an  unavoidable  cause  of  death,  is  not  necessarily  a  com- 
plication of  the  local  disease,  except  insofar  as  a  lowered  vitality 
may  predispose  the  patient  to  it,  since  it  may  have  been  due  to  new 
infection  or  induced  by  the  primary  focus  which  preceded  the  tuber- 
culosis of  the  hip. 

It  is  believed  that  operative  interference  is  sometimes  the  direct 
cause  of  tuberculous  meningitis,  and  it  is  of  interest  in  this  connec- 
tion to  note  that  20  of  50  deaths,  or,  rather  of  34,  in  which  the  cause 
of  death  w^as  known  (58  per  cent.),  were  due  to  this  complication 
among  the  cases  treated  at  the  New  York  Orthopedic  Dispensary 
and  Hospital,  where  no  operations  were  performed.^  While  of  52 
deaths  in  a  total  of  99  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled,  in  which  excision  was  performed,  but  9  were  caused  by 
tuberculous  meningitis. ^ 

The  normal  death-rate  among  cases  under  fair  hygienic  con- 
ditions is  illustrated  by  statistics  from  the  Hospital  for  Ruptured 
and  Crippled  at  a  time  when  no  operative  or  mechanical  treatment 
was  employed.^  This  was  12.5  per  cent.;  4.5  per  cent,  from  exhaus- 
tion, 4.5  per  cent,  from  amyloid  degeneration,  1.75  per  cent.,  from 
tuberculous  meningitis,  1.75  per  cent,  from  intercurrent  diseases. 

Thus  nearly  75  per  cent,  of  the  deaths  were  due  more  or  less 
directly  to  suppuration. 

Functional  Results. — In  a  certain  proportion  of  cases  perfect 
function  may  be  retained,  the  proportion  depending  upon  the 
accuracy  of  diagnosis  in  excluding  mUd  types  of  arthritis  or 
affections  which  are  often  mistaken  for  tuberculous  disease;  upon 
the  situation  and  the  extent  of  the  disease,  and  upon  the  timeliness 
and  efficiency  of  the  treatment. 

1  Shaffer  and  Lovett:  New  York  Med.  Jour.,  May  21,  1887, 

2Townsend:   Med.    News,    June    26,    1896. 

3  Gibney:  New  York  Med.  Rec,  March  2,  1878. 


PROGNOSIS  395 

Recovery  with  perfect  function  which  implies  a  normal  joint  arid 
therefore  a  limited  area  of  disease  is  not  a  test  of  relative  efficiency 
of  mechanical  treatment  sin'^e  approximately  the  same  result  might 
be  attained  by  any  form  of  adequate  protection. 

In  a  total  of  280  cases  from  the  private  practice  of  Dr.  L.  A. 
Sayre/  in  which  the  final  results  were  known,  73,  or  26  per  cent., 
recovered  with  perfect  motion,  and  120  or  42  per  cent.,  retained 
good  motion.  These  results  are  extraordinarily  good,  very  much 
better  than  any  others  that  have  been  reported,  and,  of  course,  far 
better  than  may  be  expected  in  the  ordinary  class  of  cases  in  which 
the  diagnosis  has  been  confirmed. 

In  a  series  of  51  cases  illustrating  final  results  of  treatment  at  the 
Boston  Children's  Hospital,  there  was  practical  fixation  at  the  joint 
in  33  (60  per  cent.).  In  16  perfect  motion  was  retained.  Adduction 
was  present  in  21  (40  per  cent.).  The  trochanter  was  above  Nelaton's 
line  in  19  (37  per  cent.^). 

In  35  final  results  treated  by  the  traction  hip  splint  at  the  New 
York  Orthopedic  Dispensary  practical  fixation  was  present  in  74 
per  cent,  of  the  patients.^  The  report  of  a  recent  investigation  of 
cases  treated  at  the  same  Institute  is  presented  in  detail.^ 

Hip-joint  Disease. 

Total  numl)er  of  cases  of  hip-joint  disease  treated 461 

Number  of  boys  treated 236 

Number  of  girls  treated 225 

Number  of  cases  with  right  hip  involved 242 

Number  of  cases  with  left  hip  involved 219 

Average  duration  of  disease  on  admission,  years 2 

Average  age  on  admission,  years 7 

Average  duration  of  treatment,  years 7^ 

Number  patients  cured 171 

Number  under  treatment  at  present  time 44 

Number  died 60 

Number  could  not  be  located 215 

Of  cases  cured,  number  with  less  than  1  inch  shortening  ....  40 

Number  with  less  than  2  inches  shortening 59 

Number  with  less  than  3  inches  shortening 60 

Number  with  more  than  3  inches  shortening 21 

Number  with  adduction  and  flexion  deformity  combined    ...  36 

Number  with  flexion  without  adduction  deformity 17 

Number  with  bony  ankylosis 13 

Number  with  fibrous  ankylosis 49 

Number  with  no  destruction  of  femoral  head  (Roentgen  examina- 
tion)          32 

Number  with  partial  destruction  of  femoral  head  (Roentgen  exami- 
nation)    86 

Number  with  complete   destruction   of  femoral  head    (Roentgen 

examination) 88 

Number  with  partial  acetabular  destruction  but  no  evidence  of 

disease  of  femoral  head  (Roentgen  examination) 6 

Number  with  dislocation  (Roentgen  examination) 3 

Number  with  thigh  flexion  from  15  to  90  degrees 73 

Number  with  more  than  90  degrees  thigh  flexion      ..'...  45 

Number  with  perfect  function  without  deformity 35 

Number  wiMi  relaxation  of  knee-joint 20 

1  New  York  Med.  Jour.,  April  30,  1892. 

2  Bradford  and  Soutter:  Loc.  cit.  3  Loc.  cit. 
^Humphries  and  Durham,  Am.  Med.  Assn.,  January  27,  1917. 


396  TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 

The  effect  of  mechanical  treatment  and  of  the  various  measures 
employed  for  the  correction  of  deformity  is  well  illustrated  in  two 
series  of  ultimate  results  in  cases  treated  at  the  Hospital  for  Rup- 
tured and  Crippled,  reported  by  Gibney.^  In  the  first  series  of 
80  cases  no  mechanical  or  operative  measures  were  employed,  the 
treatment  being  simply  hygienic  and  symptomatic;  the  results 
therefore  represent  natural  cure  under  supervision.  The  duration 
of  the  disease  was  three  years  in  23;  three  to  six  years  in  28;  six  to 
ten  years  in  16,  and  fifteen  years  in  1  case. 

In  35  cases  the  shortening  was  two  inches  or  more,  and  in  nearly 
every  case  there  was  more  or  less  deformity,  viz. : 

In    2  there  was  flexion  to 90 

In    3  there  was  flexion  to 110 

In    3  there  was  flexion  to 120 

In  19  there  was  flexion  to 135 

In  19  there  was  flexion  to 145 

In  18  there  was  flexion  to 150 

In  11  there  was  flexion  to 160-170 

In  4  no  estimate  was  made.  Distortions  other  than  flexion  are 
not  specified. 

In  12  instances  motion  was  retained  of  from  15  to  90  degrees. 

In  the  second  series^  of  107  cured  cases  mechanical  and  operative 
treatment  was  employed,  although  the  protection  assured  was  in 
many  instances  far  from  efficient.  In  many  of  these  cases  the  dis- 
ease was  in  an  advanced  stage,  and  deformity  was  present  in  more 
than  half  of  the  number  when  treatment  was  begun,  and  yet  all  of 
them  recovered  without  marked  flexion  and  presumably  without 
adduction,  as  this  deformity  is  not  mentioned. 

No  flexion 47 

Flexion  of  10° 30 

Flexion  of  10  to  20° 20 

Flexion  of  20  to  30° 10 

107 

In  69  cases  the  shortening  was  one  inch  or  less,  35  having  no  short- 
ening.    In  38  it  was  more  than  one  inch. 

Perfect  motion  was  retained  in 13 

Good  motion  was  retained  in 22 

Limited  motion  was  retained  in        41 

There  was  anchylosis  in 31 

107 

As  has  been  stated,  the  mechanical  treatment  in  these  cases  was 
not  sufficiently  eftective  to  prevent  deformity,  and  to  attain  these 

1  Loc.  cit. 

2  Gibney,  Waterman,  and  Reynolds:  Tr.  Am.  Orthop.  Assn.,  1898,  xi. 


PROGNOSIS  397 

results  osteotomy  with  or  without  division  of  contracted  tissues  was 
performed  in  19  cases,  forcible  correction  with  or  without  tenotomy 
in  30  cases,  and  in  4  cases  the  joint  was  excised. 

If  the  joint  has  been  actually  invaded  by  disease  so  that  a  part 
of  its  articulating  surface  has  been  destroyed,  motion  must  be 
impeded  both  in  area  and  quality.  In  such  cases  the  joint  is  some- 
what weakened,  and  it  is  often  sensitive,  although  in  many  instances 
not  to  the  extent  of  interfering  seriously  with  the  ability  of  the 
patient.  In  this  class  discomfort  in  damp  weather  or  pain  on  over- 
exertion is^  experienced,  symptoms  similar  to  those  complained  of 
by  rheumatic  subjects.  Absolute  anchylosis  is  therefore  a  far 
more  satisfactory  result  in  patients  of  the  laboring  class. 

Simple  shortening,  due  to  retardation  of  growth,  unaccompanied 
by  deformity,  is  of  comparatively  little  importance.  Firm  anchy- 
losis in  a  symmetrical  position  ensures  a  strong  and  useful  limb,  the 
flexibility  of  the  lumbar  region  compensating  for  the  loss  of  motion 
at  the  joint.  In  such  cases  the  disability  may  be  very  slight,  and 
the  effect  of  the  loss  of  motion  may  be  more  apparent  in  the  sitting 
than  in  the  erect  posture,  for  the  patient  must,  as  it  were,  sit  upon 
his  back,  an  attitude  which  perceptibly  reduces  the  sitting  height. 

Flexion,  if  of  moderate  degree,  does  not  cause  disability,  but 
flexion  of  more  than  30  degrees  increases  the  lumbar  lordosis  and 
makes  the  buttock  prominent,  the  deformity  so  characteristic  of 
the  natural  cure  (Fig.  249) .  Great  flexion,  for  example  of  60  to  90 
degrees,  causes  an  exaggerated  lordosis  which  is  almost  always  a 
source  of  pain  or  discomfort  to  a  patient  who  is  obliged  to  stand 
much  of  the  time. 

Abduction,  unless  of  an  extreme  degree,  is  of  advantage  since  it 
serves  as  a  compensation  for  actual  shortening  of  the  limb. 

Adduction,  on  the  other  hand,  which  necessitates  an  upward 
tilting  of  the  pelvis  in  order  to  restore  the  parallelism  of  the  limbs, 
is  the  most  disastrous  of  all  the  distortions,  since  it  causes  a  prac- 
tical shortening  often  greater  than  that  due  to  the  destructive 
effects  of  the  disease. 

The  motion  that  is  retained  after  recovery  from  hip  disease  is 
usually  considered  as  the  test  of  successful  treatment.  This  is  by 
no  means  the  fact,  for  in  many  instances  motion  is  preserved  because 
the  joint  is  destroyed  and  because  what  remains  of  the  upper  extrem- 
ity of  the  femur  is  supported  by  the  tissues  on  the  dorsum  of  the 
ilium — a  form  of  pathological  dislocation.  Motion  thus  explained 
is  an  indication  of  inefficient  treatment  rather  than  of  success,  for 
in  such  cases  deformity  is  almost  always  present,  and  the  support 
is  insecure. 

Deformity  is  far  more  disabling  than  loss  of  motion,  and  the  best 
safeguard  against  final  deformity  is  to  prevent  it  during  treatment, 
and  to  retain  so  far  as  may  be  the  joint  surfaces  in  proper  relation 
to  one  another.     Whatever  motion  is  preserved  will  then  be*of  ser- 


398  TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT 

vice  to  the  patient,  and  even  if  anchylosis  follows  the  result  may  still 
be  classed  as  good. 

Deformities  of  Other  Parts  Caused  by  Hip  Disease. — Deformities  of 
other  parts  are  often  observed  as  secondary  results  of  hip  disease, 
usuallj^  in  cases  that  have  not  received  proper  treatment.  In  the 
spine  an  exaggerated  lordosis  as  a  compensation  for  flexion  is  not 
uncommon,  and  lateral  curvature  may  follow  distortion  of  the  pelvis 
caused  by  adduction.  In  the  limb  hnocli-knee  may  follow  persistent 
adduction  of  the  thigh,  or  it  may  be  an  effect  of  laxity  of  the  liga- 
ments without  such  distortion.  Another  deformity  is  genu  recur- 
vatwn.  This  is  apparently  caused  by  primarily  long-continued 
disuse  of  the  limb,  and  by  the  use  of  apparatus  in  which  the  knee  has 
not  been  properly  supported  and  as  a  compensation  for  deformity. 
It  is  supposed  to  be  one  of  the  effects  of  traction,  but  it  is  also  ob- 
served in  cases  in  which  traction  has  never  been  employed.  In 
cases  in  which  the  muscular  atrophy  is  great,  laxity  of  the  ligaments 
of  the  knee-joint  is  common,  and  not  infrequently  subluxation  of  the 
tibia  also.  A  slight  degree  of  equinus  with  accompanying  exaggera- 
tion of  the  arch  is  not  uncommon  among  patients  who  have  been 
treated  by  the  traction  apparatus,  in  which  the  foot  is  pendent  and 
in  which  the  toes  are  often  inclined  downward  to  guide  the  brace  in 
walking.  Practically  speaking,  all  these  secondary  deformities  may 
be  avoided  by  proper  supervision  of  the  patient  during  the  period 
of  treatment. 

As  a  rule  patients  who  have  recovered  from  hip  disease  finally 
discard  all  apparatus,  or  at  most  use  only  a  cane  as  a  support,  and 
many  prefer  to  walk  habitually  on  the  toe  rather  than  to  equalize 
the  length  of  the  limbs  by  a  special  shoe. 

By  far  the  larger  number  of  this  class,  having  accommodated 
themselves  to  whatever  weakness  and  distortion  may  be  present 
are  able  to  undertake  the  ordinary  occupations  of  life.  Of  the  cases 
reported  by  Bradford  and  Soutter  98  per  cent,  of  the  patients 
recovered  with  useful  limbs.  Of  the  patients  treated  at  the  New 
York  Orthopedic  Dispensary  and  Hospital  in  the  report  already 
referred  to,  in  whom  the  final  results  as  regards  motion  and  sym- 
metry were  certainly  not  above  the  average,  it  is  stated  that  there 
was  not  a  single  individual  who  was  incapacitated  from  doing  a  full 
day's  work  at  his  or  her  trade  or  occupation.  None  used  crutches 
and  but  one  used  a  cane. 


25  per  cent. 


CHAPTER  VIII. 

NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT. 

The  relative  frequency  and  importance  of  the  various  affec- 
tions of  the  hip-joint  that  cause  disability  are  indicated  by  the 
following  statistics  of  Konig's^  clinic  at  Gottingen: 

Tuberculous  disease 568      =     75  per  cent. 

Infectious  arthritis  following  typhoid  fever: 

Scarlatina  and  the  like 110 

Gonorrheal  arthritis 30 

Arthritis  deformans 22 

Injuries 11 

Contractions,  cause  unknown        ....  6 

Coxa  vara 5 

Tumors 2 

Pyemic  suppuration 3 

757, 

Several  of  the  affections  enumerated  are  very  uncommon  in 
childhood,  while  injury  and  coxa  vara  are  relatively  more  important. 
Coxa  vara  and  fracture  of  the  neck  of  the  femur  in  early  life  are 
considered  at  length  in  Chapter  XV. 

TRAUMATISMS  AT  THE  HIP-JOINT. 

It  is  probable  that  injury  at  the  hip-joint,  or  functional  strains, 
may  induce  congestion  about  the  epiphyseal  cartilage  of  the  head 
of  the  femur.  In  this  class  of  cases  there  is  usually  discomfort  at 
night  after  overexertion,  "growing  pain,"  and  there  may  be  a  limp 
and  restriction  of  motion.  These  symptoms  may  disappear  in  a 
few  days  or  they  may  recur  from  time  to  time.  If  the  injury  is 
more  severe  there  may  be  local  sensitiveness  and  even  swelling — 
synovitis.  This  congestion,  with  the  lessened  local  resistance 
induced  by  it,  may  be  a  predisposing  cause  of  tuberculous  disease. 
Injury  of  the  cartilage  and  of  the  underlying  bone  may  cause  per- 
sistent discomfort,  limitation  of  motion  and  eventually  nutritive 
changes  in  the  joint  (arthritis  deformans  of  adolescence).  Undoubt- 
edly cases  of  this  type  are  sometimes  mistaken  for  hip  disease  and 
go  to  swell  the  number  of  favorable  results  ascribed  to  one  or  another 
system  of  treatment. 

Treatment. — All  cases  of  this  class  require  careful  supervision. 
Strains  or  other  injuries  in  young  children  are  best  treated  by  a  sup- 
porting bandage  and  by  rest  in  bed  until  the  symptoms  disappear. 
If  the  sensitive  condition  persists,  protective  treatment  by  a  brace, 

1  Das  Huftgelenk,  Berlin,  1902. 


400 


XOX~TUBERCULOUS  AFFECTIOXS  OF  HIP-JOIXT 


preferably  the  ordinary  traction  hip  sphnt,  or  by  a  short  plaster 
bandage,  should  be  employed,  the  diagnosis  being  reserved  until  it 
is  made  clear  by  the  progress  of  the  case.  Chronic  synovitis  of  the 
hip-joint,  especially  in  the  adolescent  or  adult,  unless  it  is  a  direct 
result  of  injury,  is  usually  tuberculous  in  character. 


ARTHRITIS. 

Acute  Infectious  Arthritis — Acute  Epiphysitis  at  the  Hip-joint. — 

Acute  epiphysitis,  caused  by  infection  with  pyogenic  germs,  is  not 

uncommon  in  infancy  and  early  childhood. 
Of  52  cases  in  which  but  a  single  joint 
was  involved  the  hip  was  affected  in  26.^ 
In  some  instances  it  is  secondary  to  an 
infected  wound,  suppurating  ear  and  the 
like;  it  may  follow  pneumonia  or  one  of 
the  exanthemata,  and  its  location  may  be 
determined  by  injury. 

Symptoms.  —  The  s^^nptoms  are  of 
sudden  onset,  accompanied  usually  by 
high  fever  and  prostration.  The  hip  be- 
comes swollen,  hot,  and  sensitive  both  to 
motion  and  pressiue. 

Treatment. — The  treatment  is  early  and 
free  incision  and  efficient  drainage,  the 
limb  being  afterward  supported  by  some 
form  of  splint.  In  neglected  cases  a  spon- 
taneous opening  forms  and  suppuration 
ordinarily  persists  for  several  months; 
the  epiphysis  is  usually  destroyed  in 
whole  or  in  part,  and  in  consequence  the 
joint  becomes  somewhat  loose  and  flail- 
like (Fig.  319).  Many  of  these  cases  seen 
in  later  years,  but  for  the  history  and 
the  scars  about  the  joint,  might  be  mis- 
taken for  congenital  dislocation.  In  cer- 
tain instances  the  symptoms  are  less  acute 
and  the  diagnosis  from  tuberculous  disease 
can  be  made  positively  only  after  a  bac- 
teriological examination  of  the  fluid  that 
may  be  removed  from  the  joint  by  aspir- 
ation. 

In  the  class  of  cases  in  which  the  dis- 
ease is  confined  to  one  joint  and  in  which  the  shaft  of  the  bone  is 
not  involved,  the  prognosis  is  good  if  the  pus  is  thoroughly  evacu- 


FiG.  319.— The'later  effect 
of  acute  epiphysitis  of  the 
right  hip  at  three  months  of 
age.     The  scar  is  shown. 


*  Townsend:  Am.  Jour.  Med.  .Sc,  Januarv,  1890. 


SPONTANEOUS  DISLOCATION  OF   THE  HIP-JOINT     401 

ated.  In  12  cases  treated  at  the  Hospital  for  Ruptured  and  Crippled 
there  were  3  deaths.^  The  prognosis  as  to  function  under  these 
conditions  is  much  better  than  in  tuberculous  disease. 

After  recovery  the  joint  should  be  supported  for  a  time  in  exten- 
sion and  abduction  to  prevent  displacement.  If  the  head  of  the 
femur  has  been  destroyed  there  is  usually  upward  and  backward 
dislocation.  This  induces  flexion  and  adduction  of  the  limb  and 
great  disability.  In  such  cases  one  should,  under  anesthesia,  force 
the  femur  forward  to  the  neighborhood  of  the  anterosuperior 
spine  and  to  fix  it  there  for  a  long  period  by  the  application  of  a 
Lorenz  spica  bandage  applied  with  the  limb  in  an  attitude  of  abduc- 
tion and  hyperextension.  The  operation  is  in  detail  similar  to  the 
Lorenz  method  for  replacing  the  congenital  dislocation.  (See  Con- 
genital Dislocation  of  the  Hip.)  If  this  is  unsuccessful  the  upper 
extremity  of  the  femur  may  be  implanted  in  the  acetabulum  by 
open  operation. 

Subacute  Arthritis. — In  the  forms  of  arthritis  that  may  com- 
plicate infectious  diseases  several  joints  are  usually  involved,  and 
the  affection  is  often  subacute  in  character. 

Undoubtedly  there  are  mild  cases  of  infection  at  the  hip-joint 
terminating  in  partial  or  complete  recovery.  In  such  cases,  often 
classed  as  rheumatism,  there  is  usually  some  infiltration  about  the 
hip,  flexion  deformity,  limitation  of  motion,  and  pain  or  discomfort 
referred  to  the  affected  joint.  A  satisfactory  treatment  is  the  appli- 
cation of  ichthyol  ointment  in  a  strength  of  about  25  per  cent.,  the 
joint  being  fixed  by  a  posterior  wire  splint  or  light  Thomas  hip  brace. 

Hoke  has  reported  cases  of  what  he  calls  toxic  arthritis  due  to 
intestinal  putrefaction.  Prompt  evacuation  of  the  bowels  and 
regulation  of  the  diet  are  the  first  indications  in  cases  of  this  type. 

Gonorrheal  Arthritis, — Gonorrheal  arthritis  of  this  joint  is  a 
an  affection  not  uncommon  in  adult  life,  and  in  its  symptoms  and 
effects  it  may  resemble  tuberculous  disease  or  perhaps  more  closely 
osteo-arthritis.  The  treatment  of  infectious  arthritis  in  general  is 
discussed  elsewhere.  Deformity  should  be  corrected  by  rest  in 
bed  with  traction,  and  protective  treatment  should  be  employed 
while  the  sensitiveness  persists.  The  short  spica  plaster  bandage, 
if  properly  applied,  is  a  satisfactory  support. 

SPONTANEOUS  DISLOCATION  OF  THE  HIP-JOINT. 

If  the  hip-joint  becomes  distended  with  fluid  the  capsule  may  be 
ruptured  and  sudden  displacement  may  occur. 

Degez^  has  collected  from  literature  79  cases  of  this  character. 
The  displacement  occurred  in  the  course  of  the  following  diseases: 

1  Townsend:  Loc.  cit. 

2  Rev.  d'Orthop.,  January  1,  1899. 
26 


402        XOX-TUBERCULOUS  AFFECTIONS  OF  HIP-JOINT 

Typhoid  fever 32 

Rheumatism 24 

Scarlatina 13 

Variola 3 

Gonorrheal  artliritis 3 

La  grippe 2 

Erysipelas 1 

Eruptive  fever 1 

Such  accidents^  may  be  guarded  against  by  preventing  flexion 
and  adduction  or  extreme  outward  rotation  of  the  limb  and  by 
evacuation  of  the  fluid  that  distends  the  joint.  The  femur  should 
be  replaced  as  soon  as  possible  before  it  has  become  fixed  by  adhe- 
sions and  contractions.  Even  if  treatment  has  been  delayed  for 
months,  by  means  of  preliminary  traction  and  by  the  use  of  manual 
force,  as  in  the  reduction  of  congenital  dislocation,  one  may  succeed 
in  replacing  the  femm".  In  cases  of  longer  standing  the  acetabulum 
is  usually  filled  with  new  material,  which  must  be  removed  by  the 
open  method  before  replacement  is  possible.  As  an  alternative 
operation  one  may  force  the  head  of  the  femur  into  the  anterior 
position  and  fix  the  limb,  for  several  months,  in  the  attitude  of  exten- 
sion and  abduction.  If  the  outward  rotation  is  excessive,  or  if  a 
tendency  toward  adduction  persists,  a  secondary  osteotomy  of  the 
shaft  below  the  trochanter  minor  may  be  performed.  However 
early  reduction  is  accomplished,  limitation  of  motion  is  to  be 
expected,  and  in  many  instances  absolute  anchylosis.  On  this 
account  the  limb  should  be  supported  for  a  time  in  proper  position 
in  order  to  prevent  deformity. 

EXTRA-ARTICULAR  DISEASE. 

Occasionally  tuberculous  disease,  or  other  form  of  destructive 
ostitis,  may  begin  in  the  neighborhood  of  the  trochanter  major. 
The  sjTnptoms  are  local  pain,  sensitiveness,  and  swelling  of  the 
soft  parts.  Later  thickening  and  irregularity  of  the  underlying 
bone  become  evident. 

The  symptoms  are  limp  and  discomfort.  If  the  disease  involves 
the  capsule  or  is  sufficiently  acute  to  cause  s^Tnpathetic  congestion 
of  the  joint,  there  may  be  general  limitation  of  motion;  but,  as  a  rule, 
this  is  slight  or  absent.  In  many  instances  the  focus  in  the  bone 
may  be  demonstrated  by  an  .r-ray  negative.  If  the  disease  is 
tuberculous  or  of  the  subacute  ty^e,  abscess  in  the  trochanteric  or 
gluteal  region  may  be  the  first  indication  of  disease. 

The  treatment  is  prompt  removal  of  the  focus  of  disease  before 
the  joint  or  the  shaft  of  the  femur  has  become  involved. 

Disease  of  the  pelvic  bones  in  the  neighborhood  of  the  joint  may 
simulate  hip  disease.     The  diagnosis  is  made  by  the  local  swelling 


1  Graff:  Deutsch.  Ztschr.  f.  Chir.,  February, 


1902. 


MALIGNANT  DISEASE  ABOUT   THE  HIP-JOINT       403 

and  sensitiveness,  and  by  the  freedom  of  motion  in  the  directions 
not  restrained  by  sensitive  tissues  that  are  involved  in  the  disease. 

Gluteal  Bursitis. — An  enlargement  of  one  of  the  bursse  lying 
beneath  the  gluteal  muscles  may  cause  a  rounded,  fluctuating  swell- 
ing in  the  buttock.  It  may  be  sensitive  to  pressm-e  and  it  usually 
causes  a  limp  and  some  discomfort  on  motion,  dependent  upon  the 
degree  of  inflammation  that  may  be  present.  Occasionally  the 
bursitis  may  be  caused  by  injury,  but  in  most  instances  it  is  the  result 
of  tuberculous  infection.  The  bursa  may  communicate  with  a  dis- 
eased hip-joint,  but  usually  it  is  a  distinct  and  primary  affection. 

Iliopsoas  Bursitis. — The  iliopsoas  bursa  is  of  a  conical  form 
about  two  and  one-half  inches  in  length  and  one  and  one-fourth  at 
its  widest  part.  It  lies  base  upward  in  front  of  the  capsule  of  the 
hip-joint,  extending  from  the  trochanter  minor  to  and  sometimes 
over  the  brim  of  the  pelvis.^  Not  infrequently  it  communicates  with 
the  joint.  If  the  bursa  is  enlarged  it  forms  a  swelling  in  Scarpa's 
space  of  a  somewhat  quadrilateral  form.  Sometimes  a  central 
indentation  indicates  the  position  of  the  iliopsoas  tendon.  This 
causes  a  distinct  enlargement  of  the  upper  and  inner  aspect  of  the 
thigh.  It  is  usually  accompanied  by  slight  flexion,  abduction,  and 
outward  rotation  of  the  limb,  an  attitude  that  relieves  the  tension 
on  the  sensitive  part.  Zuelzer  has  collected  from  literature  45  cases 
of  gluteal  and  15  of  iliopsoas  bursitis.  This  illustrates  the  relative 
frequency  of  the  two  affections.^ 

Simple  bursitis  may  be  distinguished  from  disease  of  the  joint 
by  the  absence  of  characteristic  muscular  spasm  and  general  limita- 
tion of  motion.  Acute  inflammation  of  a  bursa  may  simulate  local 
abscess. 

Treatment. — Chronic  disease  of  bursse  is  usually  tuberculous  in 
character.  Aspiration  and  injection  of  carbolic  acid  or  iodoform 
emulsion  may  be  employed  as  primary  measures.  As  a  rule,  how- 
ever, incision,  drainage,  or,  if  possible,  removal  of  the  sac  is  indi- 
cated. The  iliopsoas  bm-sa  may  be  reached  easily  by  a  vertical 
incision  between  the  femoral  artery  and  the  crural  nerve. 

MALIGNANT  DISEASE  ABOUT  THE  HIP-JOINT. 

Carcinoma  of  the  upper  extremity  of  the  femur  is  almost  always 
secondary  to  a  primary  tumor  elsewhere,  as  of  the  breast  or  prostate. 
It  is  not  uncommon  in  elderly  subjects.  The  symptoms  are  often 
indefinite  and  fracture  of  the  weakened  bone  may  be  the  first  indi- 
cation of  the  disease.  Sarcoma  is,  on  the  other  hand,  practically 
limited  to  youthful  subjects  and  is  usually  primary,  and  is  far  less 
frequent  in  this  situation  than  at  the  knee.     The  character  of  the 

1  Lund:  Boston  Med.  and  Surg.  Jour.,  September  25,  1902. 

2  Deutsch.  Ztschr.  f.  Chir.,  Band  i,  Heft  1  and  2. 


404        N  ON -TUBERCULOUS  AFFECTIONS  OF  HIP-JOINT 

disease  soom  becomes  evident  in  the  general  enlargement  of  the 
upper  extremity  of  the  thigh,  but  in  the  early  stage  diagnosis  can 
be  made  only  by  means  of  the  x-Ta,Y  or  by  exploratory  incision. 

CYSTS  OF  THE  FEMUR. 

In  rare  instances  cysts  may  cause  enlargement,  weakening,  'and 
deformity  of  the  upper  extremity  of  the  femur.  The  symptoms  are 
discomfort,  limp,  and  outward  bowing  of  the  upper  third  of  the 
femur.  Of  24  cases  reported  13  were  of  the  upper  extremity  of  the 
femiu-,  1  of  the  lower  end,  3  of  the  upper  extremity  of  the  tibia,  3  of 
the  upper  portion  of  the  humerus.  The  affection  is  usually  dis- 
covered diu"ing  the  growing  period,  the  sjTiiptoms  often  becoming 
apparent  after  injiuy,  which  may  be  also  an  exciting  cause.  In 
some  instances  spontaneous  fracture  occurs.^ 

Cysts^  may  be  caused  by  the  organization  of  a  blood  clot,  but 
usually  by  localized  osteomyelitis  of  a  mild  character  or  by  congenital 
inclusion  of  cartilage.  In  some  instances  repair  follows  if  the  joint 
is  protected  by  a  splint.  Otherwise  operative  removal  is  indicated 
by  an  opening  through  the  trochanter. 

OSTEITIS  FIBROSA. 

This  is  characterized  by  enlargement  and  deformity,  usually 
outward  bowing  in  the  neighborhood  of  the  trochanter,  by  limp 
and  discomfort  as  the  bones  become  weaker.  The  x-ray  shows  a 
general  blurring  in  place  of  the  marrow  and  cortex.  As  a  rule 
operative  removal  of  the  diseased  tissue  is  indicated.  Osteitis 
Fibrosa  is  described  elsewhere. 

ARTHRITIS  DEFORMANS. 

Osteo-arthritis  of  the  Hip-joint. — Osteo-arthritis  is  not  infre- 
quently confined  to  the  hip-joint.  In  this  form  it  is  practically  an 
affection  of  adult  life  or  old  age  (malum  coxse  senile),  although  it 
occasionally  occurs  in  young  subjects.  It  is  far  more  common  in 
males  than  in  females.  It  is  characterized  in  its  later  stages  by  dis- 
appearance of  the  cartilage  covering  the  head  of  the  femur  and  by 
an  eburnation  and  progressive  destruction,  or  wearing  away,  of  the 
underlying  bone  with  formation  of  ecchondroses  about  the  junction 
of  the  femur  with  the  acetabulum,  which  may  become  ossified  into 
irregular  masses  of  bone.  In  the  early  stage  of  the  affection  the 
fluid  within  the  joint  may  be  increased  in  amount,  but  later  it  is 
diminished  in  quantity  and  changed  in  quality  as  the  synovial  mem- 
brane becomes  transformed  in  part  to  fibrous  tissue.  The  etiology 
of  the  affection  is  discussed  elsewhere.     (See  page  283.)     At  this 

1  Mikulicz:  Ztschr.  f.  Chir.,  November  19,   1904. 
-'  Ropke:  Arch.  f.   Klin.   Med.,   Band  i,   s.   126. 


ARTHRITIS  DEFORMANS 


405 


joint,  injury  and  congenital  or  acquired  predisposition,  so-called 
incongruity  in  the  articulation  are  of  especial  importance. 


Fig.  320. — Arthritis  deformans. 


Fig.  321. — ^Arthritis  deformans,  showing  changes  in  the  head  and  subluxation. 

(Kohler.) 


406        XOX-TUBERCULOUS  AFFECTIONS  OF  HIP-JOINT 

Symptoms. — The  early  s^Taptoms  are  iisiiaUy  subacute  in  char- 
acter. They  are  neiualgic  pain  in  the  limb,  "sciatic  rheumatism," 
stiffness  on  changing  from  rest  to  activity,  and  sensitiveness  to 
direct  pressure  on  the  joint,  so  that  the  patient  often  lies  habitually 
on  the  other  side.  The  movements  of  the  joint  become  somewhat . 
restricted,  and  the  patient  notices  that  he  cannot  take  a  long  step 
or  ride  with  comfort.  In  many  instances  creaking  or  grating  in  the 
joint  is  noticeable.  In  advanced  stages  of  the  disease  there  is 
marked  thickening  about  the  trochanter  which  is  usually  displaced 
upward,  owing  to  the  progressive  changes  in  the  acetabuhun  and  in 
the  head  and  neck  of  the  femur.  The  limb  is  shortened  and  it  is 
often  distorted,  usually  in  an  attitude  of  flexion  and  adduction,  and 
marked  atrophy  is  apparent,  appearances  that,  but  for  the  history, 
might  be  mistaken  for  fracture.  So  also  in  the  earlier  period  of  the 
disease  the  limp,  the  pain,  and  restriction  of  motion  with  the  attend- 
ant atrophy  may  simulate  very  closely  tuberculous  disease  of  a  sub- 
acute t;s'pe. 

The  progress  of  the  disease  may  be  very  slow  or  it  may  be  rapid, 
its  progress  being  dependent  in  great  degree  upon  the  strain  to  which 
the  part  is  subjected.     In  this  it  resembles  tuberculous  disease. 

Treatment. — In  the  class  of  cases  in  which  the  disease  is  confined 
to  a  single  joint  one  may  hope  to  check  the  progress  of  the  destruc- 
tive process  by  lessening  the  strain  upon  the  joint  by  regulation  of 
the  patient's  habits  and  occupation,  and  to  improve  the  nutrition 
of  the  part  by  massage  and  local  stimulants.  Passive  motion  in 
the  directions  of  abduction  and  extension,  for  the  purpose  of  pre- 
venting secondary  contraction  of  the  muscles,  is  of  service  also. 

If  deformity  is  present  it  should  be  reduced  by  traction  and  rest  in 
bed  or  by  carefuUy  regulated  force  under  anesthesia.  Afterward 
a  hip  brace  (Fig.  297)  that  wiU  remove  the  weight  and  limit  the 
range  of  motion,  or  a  support  of  the  character  of  a  Lorenz  spica  of 
plaster,  leather,  or  other  material  may  be  used. 

Operative  Treatment. — In  exceptional  instances  the  s^Tnptoms  are 
induced  by  marginal  exostoses,  the  articulating  cartilage  being  in 
apparently  normal  condition.  In  such  instances  relief  follows  their 
removal.  If  the  cartilage  is  in  great  part  destroyed  the  head  may 
be  reduced  in  size  or  it  may  be  removed  and  the  neck  implanted  in 
the  acetabuhun.  The  most  satisfactory  treatment  of  advanced  cases 
attended  by  adduction  deformity  cases  is  the  induction  of  anchylosis 
by  Albee's  method.  The  joint  is  opened  by  an  anterior  incision  along 
the  inner  border  of  the  Sartorius  muscle.  The  upper  extremity  of  the 
head  in  the  plane  of  the  neck  and  a  sufficient  section  of  the  roof  of  the 
acetabulum  are  cut  away  with  a  chisel  so  that  the  two  sm'f  aces  may 
be  brought  into  accurate  apposition  by  abducting  the  thigh,  prefer- 
ably about  10  to  15  degrees.  To  attain  this  attitude  tenotomy  of 
the  adductors  mav  be  necessarv.     The  wound  is  closed  and  the  limb 


OSTEOCHONDRITIS  DEFORMANS  JUVENILIS  407 

is  fixed  in  a  long  spica  bandage  until  union  is  firm.  The  same  opera- 
tion may  be  employed  for  other  forms  of  chronic  disease  at  the  hip- 
joint  in  which  movement  causes  pain. 

OSTEOCHONDRITIS  DEFORMANS  JUVENILIS. 

Synonym. — Perthes'  disease. 

Osteochondritis  is  a  term  applied  to  a  class  of  cases  formerly 
mistaken  for  mild  forms  of  hip  disease.  The  name  signifies  that 
the  process  takes  place  "within  the  head  of  the  femur  and  does  not 
involve  the  cartilage  as  in  juvenile  arthritis  deformans.     It  was 


Fig.  322. — Osteochondritis.      Perthes'  disease,  showing  the  characteristic  changes 
in  the  head  of  the  femur. 

apparently  first  described  by  A.  T.  Legg/  of  Boston,  in  1909,  as  an 
obscure  affection  of  the  hip-joint,  by  Calve,^  in  1910,  under  the  name 
of  pseudocoxalgia,  and  in  more  detail  by  Perthes^  in  the  same  year. 
The  symptoms  are  limp  and  at  times  discomfort  in  the  hip  and  thigh 
on  overuse  and  strain.  There  is  usually  slight  atrophy,  and  limita- 
tion of  the  extremes  of  motion,  particularly  in  abduction  and  inward 

1  Legg:  Boston  Med.  and  Surg.  Jour.,  July  17,  1910;  Surg.,  Gynec.  and  Obst. 
March,  1916. 

2  Calve:  Rev.  de  Chir.,  July  10,  1910. 

3  Perthes:  Deutsch.  Ztschr.  f.  Chir.,  1910,  cvii,  Arch.  f.  klin.  Chir.,  1913,  779; 
Taylor,  Allison,  Kidner:  Am.  Jour.  Orthop.  Surg.,  October,  1915;  Nieber:  Ztschr. 
f.  orthop.  Chir.,  March,  1915. 


408 


K  OX -TUBERCULOUS  AFFECTIOXS  OF  HIP-JOINT 


rotation.  In  more  ad^•anced  cases  abduction  is  much  restricted 
and  there  may  be  sHght  shortening  of  the  limb.  The  diagnosis  is 
made  on  .r-ray  examination  which  shows  characteristic  changes. 
The  epiphysis  is  flattened  and  broadened  and  its  ossifying  centre 
is  distorted  and  often  segmented.  The  epiphyseal  cartilage  is 
irregular  in  outline.  The  neck  is  broader  and  shorter  than  normal 
and  the  angle  may  be  lessened.     In  some  instances  the  acetabulum 


Fig.  323. — Bilateral  osteochondiitis. 


seems  to  be  enlarged  and  irregular  in  outline.  Osteochondritis  must 
be  differentiated  from  coxa  vara,  fractured  particularly  of  the  epiphy- 
seal type  and  from  ccngenital  and  accquired  irregularities  in  the  head 
of  the  femur. 

The  disease  is  most  common  in  children  from  five  to  ten  years  of 
age.  It  is  far  more  common  in  boys  than  in  girls.  In  26  of  38 
reported  cases  it  was  unilateral. 

The  pathology  seems  to  indicate  a  lessened  resistance  of  tissue 


OSTEOCHONDRITIS  DEFORMANS  JUVENILIS  409 

with  secondary  changes,  incidental  to  weight-bearing.  The  causes 
may  be  injury,  resulting  in  disturbance  of  nutrition,  or  some  mild 
form  of  infection.  Practical  recovery  is  the  rule  without  treatment. 
The  symptoms  persist  for  a  year  or  two,  then  cease,  although  slight 
limitation  of  movement,  dependent  upon  the  mechanical  changes 
in  the  articulation  persist. 

Treatment. — This  is  symptomatic;  in  mild  cases  limitation  of  the 
activities  combined  with  massage  and  manipulation,  designed  to 
prevent  contraction,  may  be  sufficient.  If  successive  a;-ray  pictures 
show  progressive  deformity,  the  application  of  a  short  spica  or  hip 
splint  may  be  indicated.  Protection  is  advisable  because  changes 
of  this  character  in  childhood  may  predispose  to  arthritis  deformans 
in  later  life. 


CHAPTER   IX. 


TUBERCULOUS  DISEASE  OF  THE  KXEE-JOINT. 


m 


M 


Synonyms. — White  swelling,  tumor  albus. 

Tuberculous  disease  of  the  knee-joint  is  next  in  frequency  and 

importance  to  that  of  the  hip.     It  is,  however,  far  less  dangerous 

to  life,  and  the  prognosis,  as  regards 
function,  is  much  better  than  in  the 
former  affection.  This  is  accounted 
for  by  the  simplicity  of  the  joint  and 
by  its  situation  at  a  distance  from 
the  trunk,  at  the  junction  of  two 
levers  of  nearly  equal  length  and  size. 
As  the  problem  of  protection  by 
mechanical  means  is  comparatively 
simple  it  is  more  often  applied,  and 
in  proportion  to  its  efficiency  the 
injury  is  lessened  and  the  tendency 
to  deformity  is  checked. 

Pathology. — The  disease  may  begin 
in  the  epiphysis  of  the  femur  or  in  that 
of  the  tibia,  occasionally  in  the  dia- 
physis  or  in  the  patella  or  in  the  head 
of  the  fibula,  or  primarily  in  the  syno- 
vial membrane. 

In  547  cases,^  about  two-thirds  of 
which  were  in  adults,  treated  at 
Konig's  clinic  at  Gottingen  by  oper- 
ative procedures  which  permitted 
inspection  of  the  joint,  281  (51.  4  per 
cent.)  were  apparently  examples  of 
primary  osteal  disease;  266  (48.6  per 
cent.)  were  primarily  synovial.  The 
focus  was  in  the  femur  in  93  instances 
(33.1  per  cent.),  in  the  tibia  in  107 
(38.1  per  cent.),  in  the  patella  in  33 
(11.7  per  cent.),  and  in  more  than  bone 
in  48  (17.1  per  cent.). 
The  examination  of  a  joint  permitted  by  arthrectomy  or  excision 

cannot  be  sufficiently  thorough  to  exclude  disease  of  the  bone  and 

1  Die  Specielle  Tuberculose  der  Knochen  und  Gelenke,  Berlin,  1896. 


Fig.  324. — Section  of  knee-joint 
at  the  age  of  eightyears,  showing 
the  epiphyses  of  the  femur  and 
tibia  and  their  relation  to  the 
capsule.     (Krause.) 

The  centres  of  ossification  in 
the  epiphyses  of  the  femur  and 
tibia  are  present  at  birth.  Ossi- 
fication is  completed  in  each  at 
about  the  twentieth  year. 

The  range  of  motion  is  from 
slightly  more  than  complete  ex- 
tension to  about  50  to  60  degrees 
of  flexion.  In  complete  extension 
the  tibia  is  rotated  outward  on 
the  femur.  In  midflexion  the 
laxity  of  the  ligaments  permits  a 
range  of  outward  rotation  of 
about  25  degrees  while  inward 
rotation  is  limited  to  5  or  10 
degrees. 


PATHOLOGY 


411 


to  establish  the  diagnosis  of  primary  disease  of  the  synovial  mem- 
brane, but  in  92  instances  the  opportunity  was  offered  by  amputation 
at  the  thigh,  80  of  the  patients  being  adults.  This  examination, 
presumably  thorough,  showed  the  primary  disease  to  be  of  the  bone 
in  50  cases,  while  in  35  the  synovial  membrane  was  apparently  the 
seat  of  the  primary  affection.  In  17  of  the  50  cases  in  which  the 
disease  was  osteal,  the  focus  was  in  the  femur;  in  7  it  was  in  the  inter- 
nal condyle,  in  6  in  the  external  condyle,  and  it  was  in  other  situa- 


FiG.  325. — Acute  tuberculous  arthritis  of  the  knee. 


tions  in  4  cases.  In  17  the  primary  disease  was  of  the  tibia;  in  5  of 
the  internal  tuberosity;  in  5  of  the  external  tuberosity;  in  other 
situations  7.  In  5  instances  the  primary  disease  was  of  the  patella, 
and  more  than  one  bone  was  involved  in  11  cases.  Of  314  cases, 
chiefly  in  adults  treated  by  operation  in  Garre's  clinic,  13  were 
surely,  and  115  apparently,  of  synovial  origin.  In  187  cases  both 
bone  and  synovia  were  involved.  In  6  cases  the  original  disease 
was  apparently  of  the  bone,  and  in  3  surely  so.  The  femur  was 
involved  in  44  cases,  the  tibia  in  38,  the  patella  in  3,  and  more  than 


412 


TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 


one  bone  in  120  cases. ^  Nichols^  states  that  he  has  examined  120 
tuberculous  joints  of  adults  and  children,  after  excision  or  amputa- 
tion, or  at  autopsy,  and  in  every  instance  primary  foci  in  the  bone 
were  discovered.  He  believes  primary  disease  of  the  synovial 
membrane  to  be  very  uncommon,  and  asserts  that  examinations  are 
of  no  particular  value  as  establishing  the  absence  of  primary  osteal 
disease  unless  the  bones  are  sawed  into  thin  sections.  From  the 
clinical  stand-point,  however,  one  recognizes  two  distinct  types  of 
tuberculous  disease:  one  beginning  as  a  chronic  synovitis  of  which 
the  early  symptoms  are  subacute,  a  type  more  often  seen  in  adults 

(Fig.  326);  and  the  more  common 
class  especially  in  childhood,  in  which 
the  s^Tuptoms  of  pain,  muscular 
spasm,  and  deformity  seem  to  indi- 
cate clearly  primary  disease  of  the 
bone. 

The  proximity  of  the  active  dis- 
ease in  the  neighborhood  of  the 
joint  sets  up  a  s^Tnpathetic  hypere- 
mia within  it,  and  an  accompanying 
synovitis.  If  the  disease  is  progres- 
sive the  synovial  membrane  becomes 
thickened  and  adhesions  form  be- 
tween its  folds  that  gradually  lessen 
the  capacity  of  the  joint  and  diminish 
its  mobility.  When  perforation  takes 
place  the  granulation  tissue  spreads 
over  the  surface  of  the  cartilages, 
destroying  them  in  its  progress  and 
eroding  the  underlying  bone ;  or  if  the 
joint  is  filled  with  tuberculous  fluid 
the  cartilage  may  be  macerated  and 
separated  in  necrotic  shreds.  The 
direct  destructive  eft'ects  of  the  dis- 
ease are  increased  by  pressure  and 
friction  if  the  joint  is  not  protected 
by  mechanical  means.  The  h}3)er- 
trophied  synovial  membrane  and  the  thickened  and  diseased  cap- 
sule explain  the  peculiar  elastic  resistance  on  palpation  called 
pseudofluctuation.  In  more  advanced  cases  there  is  also  a  reactive 
inflammation  in  the  overlying  tissues,  accompanied  by  a  formation 
of  fibrous  tissue  that  involves  the  tendons  and  muscles.  These 
changes  withui  and  without  the  joint  cause  the  firm,  resistant 
timior  characteristic  of  "white  swelling." 


Fig.  326. — Tuberculous  disease 
of  the  knee  in  an  adult.  The 
synovial  type. 


1  Beitr.  z.  klin.  Chir.,  Ixxxvii,  Heft  1. 

2  Tr.  Am.  Orthop.  Assn.,  xi. 


SYMPTOMS  413 

Etiology. — The  etiology  of  tuberculous  disease  has  been  discussed 
in  Chapters  V  and  VII. 

Occurrence. — Tuberculosis  of  the  knee-joint  is  essentially  a  dis- 
ease of  early  life,  although  it  is  less  strictly  confined  to  childhood 
than  is  disease  of  the  spine  or  hip.  Sex  exercises  but  little  influence, 
and  the  two  sides  are  affected  in  nearly  equal  numbers.  These 
points  are  illustrated  by  the  following  table  of  1000  consecutive 
cases  treated  at  the  Hospital  for  Ruptured  and  Crippled.^ 

Age  at  Incipiency  of  Knee-joint  Disease. 

1  year  or  less        ....  25  23  years  old 12 

2  years  old 45  24  years  old 8 

3  years  old 91  25  years  old 3 

4  years  old 164  26  years  old 2 

5  years  old 84  27  years  old 4 

6  years  old 75  28  years  old 5 

7  years  old 66  29  years  old 7 

8  years  old 74  30  years  old  .....  1 

9  years  old 65  31  years  old  .....  1 

10  years  old 60  32  years  old 2 

11  years  old 46  33  years  old  ..."..  1 

12  years  old 20  34  years  old  .      .      .      ;      .  1 

13  years  old 19  35  years  old 4 

14  years  old 17  36  years  old 0 

15  years  old 12  37  years  old  .....  2 

16  years  old 10  38  years  old 1 

17  years  old 20  39  years  old 1 

18  years  old 8  40  years  old 1 

19  years  old 8  41  years  old 1 

20  years  old 8  50  years  old 1 

21  years  old 12                           '                                      

22  years  old 13                                                                1000 

Males 512         Right 485 

Females 488         Left 515 

Symptoms. — The  general  characteristics  of  tuberculosis  have 
been  described  in  the  chapters  on  Pott's  Disease  and  Hip  Disease. 
In  the  description  of  these  affections,  however,  but  little  stress  was 
laid  on  local  sensitiveness  and  local  swelling,  because  the  diseased 
parts  lie  at  a  distance  from  the  surface  and  are  concealed  by  the 
muscles  and  other  tissues.  At  the  knee,  on  the  other  hand,  the 
joint  is  superficial,  and  even  slight  effusion  changes,  to  a  perceptible 
degree,  its  contour.  If  the  disease  is  progressive,  sensitiveness  to 
pressure,  elevation  of  the  local  temperature,  and  infiltration  or 
thickening  of  the  tissues  are  usually  present. 

Even  when  the  patients  are  seen  comparatively  early  in  the 
course  of  the  disease  the  history  of  the  affection  almost  always 
indicates  that  it  is  chronic  and  progressive  in  character.  The 
importance  of  establishing  this  fact  has  been  mentioned  in  the  con- 

1  These  statistics,  together  with  those  of  tuberculous  disease  of  the  joints,  other 
than  the  hip,  were  collected  for  me  by  Drs.  F.  C.  Bradner,  S.  E.  Sprague,  E.  L. 
Barnett,  and  S.  W.  Stone,  formerly  house  officers  at  the  hospital. 


414  TUBERCULOUS  DISEASE  OF   THE  KXEE-JOIXT 

sideration  of  hip  disease,  and  it  may  be  stated  again  that  a  chronic 
painful  disease  of  a  single  joint,  accompanied  by  a  tendency  to 
deformity,  is,  in  childhood,  almost  always  tuberculous  in  character. 

The  s\Tnptoms  of  tuberculous  disease  may  be  classified  as  limp, 
pain,  local  heat,  sensitiveness  and  swelling,  muscular  spasm  and 
limitation  of  motion,  distortion  and  atrophy. 

On  physical  examination  one  will  note  the  character  of  the  limp 
and  the  slight  flexion  of  the  limb  that  usually  accompanies  it.  The 
joint  is,  as  a  rule,  somewhat  enlarged,  the  normal  depressions  about 
the  patella  and  the  prominences  of  the  component  bones  being  less 
accentuated  than  on  the  opposite  side.  There  is  usually  slight 
local  elevation  of  temperature  and  sensitiveness  to  pressure,  varying 
in  degree  with  the  character  of  the  disease.  In  certain  cases 
effusion  is  present,  sufficient  to  be  classed  as  synovitis,  but  in  most 
mstances  the  swelling  is  due,  in  great  part,  to  the  thickening  of  the 
s^^lovial  membrane  and  capsule,  which  gives  the  sensation  of  elastic 
resistance  rather  than  of  actual  fluctuation. 

Limitation  of  Motion. — The  most  important  diagnostic  sign  is 
limitation  of  the  range  of  motion  caused  by  muscular  spasm.  The 
normal  range  is  from  complete  extension  (180  degrees)  to  a  degree 
of  flexion,  limited  by  contact  of  the  calf  and  the  thigh.  Even  in  the 
early  stage  of  disease  slight  limitation  of  complete  extension  is 
present,  due  to  reflex  muscular  spasm,  and  usually  a  corresponding 
limitation  of  the  complete  flexion.  On  sudden  movements  the 
characteristic  reflex  contraction  of  the  muscles  is  apparent.  In  most 
cases  this  limitation  of  motion  and  consequent  flexion  deformity  is 
well-marked  on  the  first  examination.  Atrophy  of  the  muscles  of 
the  thigh  and  calf,  dependent  upon  the  duration  of  the  disease  and 
upon  the  interference  with  function,  is  present,  and  this  atrophy  is 
more  noticeable  because  of  the  enlargement  of  the  knee. 

In  certain  cases,  more  often  seen  in  infancy  and  early  childhood, 
the  s^Tnptoms  are  more  acute  and  the  progress  of  the  disease  is  so 
rapid  that  it  may  simulate  an  infectious  epiphysitis  (Fig.  325). 

In  another  t^-pe,  apparently  a  primary  disease  of  the  s^movial 
membrane,  more  common  in  adults,  the  early  s^Tnptoms  are  very 
similar  to  those  of  simple  chronic  synovitis.  The  joint  is  swollen 
by  a  distention  of  the  capsule,  pain  is  not  troublesome  except  on 
jars  or  sudden  twists  of  the  limb,  and  muscular  spasm  and  limita- 
tion of  motion  are  e^'ident  only  after  a  careful  examination.  In  this 
class  months  or  years  may  pass  before  the  symptoms  become  as 
disabling  as  in  the  osteal  type  of  the  disease. 

Primary  and  Secondary  Distortions.- — ^At  the  hip-joint,  in  which  the 
range  of  motion  is  extensive,  the  deformities  resulting  from  disease 
are  somewhat  complex,  causing,  for  example,  apparent  shortening 
or  lengthening,  according  as  the  limb  is  adducted  or  abducted.  But 
the  movements  that  the  knee-joints  permits  are  much  simpler,  and 
the  primary  distortion  is  simply  flexion.     Complete  extension  of  the 


SYMPTOMS  415 

limb,  the  limit  of  normal  motion  in  that  direction,  brings  the  joint 
surfaces  into  close  apposition;  the  ligaments  are  then  tense  and  no 
lateral  motion  is  permitted.  This  is  the  attitude  in  which  the  great- 
est efficiency  of  the  limb  for  weight -bearing  is  assured.  When  the 
ability  of  the  knee  for  carrying  out  its  normal  weight-bearing  func- 
tion is  impaired  by  disease  which  makes  the  parts  sensitive  to  pres- 
sure and  strain,  the  range  of  extension  is  lessened  and  the  limb  is 
persistently  flexed  to  a  greater  or  less  degree,  corresponding  to  the 
sensitiveness  of  the  joint.  The  agents  that  adapt  the  limb  to  the 
habitual  attitudes  are  the  muscles  under  the  control  of  the  nervous 
system.  In  this  sense  the  primary  distortions  are  due  to  muscular 
action,  but  it  is  certainly  not  true  that  these  muscles  antagonize 
one  another,  and  that  the  stronger  overcoming  the  weaker  cause  the 
deformity,  since  the  extensors  at  this  joint  are  stronger  than  the 
flexors,  and  since  flexion  is  the  primary  deformity  at  every  joint 
which  is  diseased  without  regard  to  the  relative  strength  of  the 
opposing  muscular  groups. 

In  disease  at  the  knee-joint,  as  at  other  joints,  the  extremes  of 
motion  in  every  direction  that  the  joint  permits  are  limited  by 
muscular  spasm,  but  limitation  of  extension,  which  is  so  essential 
to  normal  use,  is  at  once  evident,  while  limitation  of  flexion,  the 
extreme  of  which  is  unessential,  is  only  apparent  on  examination,  and 
it  may  be  absent  even.  Flexion  is,  then,  the  primary  distortion  at 
the  knee,  and  other  deformities  may  be  classed  as  secondary. 

Secondary  Deformities. — Of  these  the  most  common  is  outward 
rotation  of  the  tibia  upon  the  femur.  When  the  limb  is  fully 
extended  the  tibia  is  fixed,  but  when  it  is  flexed  lateral  motion  is 
possible  in  outward  rotation,  and  in  the  attitude  of  flexion  the  trac- 
tion of  the  biceps  upon  the  head  of  the  fibula  tends  to  rotate  it  upon 
the  femur.  This  deformity  is  also  favored  by  the  use  of  the  limb 
in  the  attitude  of  outward  rotation,  which  is  always  assumed  when 
the  weakness  or  stiffness  of  the  knee-joint  is  present,  and  by  the 
secondary  knock-knee  that  often  accompanies  the  disease. 

Subluxation  or  backward  displacement  of  the  tibia  upon  the 
femur  is  another  secondary  deformity.  When  the  leg  is  flexed  upon 
the  thigh  the  articulating  surface  of  the  tibia  glides  backward  upon 
the  condyles  of  the  femur.  Here  it  becomes  fixed  by  muscular  con- 
traction, and  later  by  the  secondary  changes  within  the  joint.  If 
muscular  spasm  is  extreme,  this  alone  may  cause  the  subluxation; 
but  there  are  other  factors:  one  is  the  destructive  action  of  the 
disease,  which  is  usually  most  marked  at  the  point  at  which  the  bones 
are  in  contact,  and  the  other  is  the  leverage  exerted  upon  the  joint. 
This  is  exemplified  by  the  increase  of  the  displacement  that  is  often 
observed  when  an  attempt  is  made  to  straighten  the  limb  by  force, 
against  the  resistance  ofi^ered  by  the  contracted  tissues  on  the  flexor 
aspect.  The  same  leverage,  in  slighter  degree,  is  exerted  when  the 
weight  of  the  distorted  limb  is  supported  on  the  heel  in  the  recum- 


416 


TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 


bent  posture,  or  when  the  Hmb  is  extended  in  the  act  of  walking,  or 
if  the  upper  extremity  of  the  tibia  is  not  supported  during  the  period 
of  treatment  by  apparatus  (Fig.  328). 


Fig.  o27. — Untreated  disease  of  the  knee-joint  involving  the  shaft  of  the  femur, 
illustrating  lengthening  and  the  hypertrophj-  of  the  femur,  the  subluxation  and  out- 
ward rotation  of  the  tibia,  the  atrophy  and  the  characteristic  deformity. 

Knock-knee  (genu  valgum)  is  another  secondary  deformity. 
This  is  explained  in  certain  instances  by  the  hypertrophy  of  the 
internal  condyle  caused  by  disease,  but  it  is  induced  more  directly 
by  the  use  of  the  flexed  and  somewhat  disabled  limb  in  the  passive 
attitude  of  outward  rotation.  Genu  varum  is  uncommon,  and  it 
is  usually  the  result  of  the  destruction  of  a  part  of  the  internal 
condyle  of  the  femur  or  of  the  tibia,  or  of  irregular  epiphyseal 
growth. 


SYMPTOMS 


417 


The  character  and  the  relative  frequency  of  the  deformities  are 
indicated  by  the  statistics  of  Konig's^  cHnic:  of  150  cases  of  knee- 
joint  disease  treated  by  arthrectomy,  128  of  these  being  in  children. 
In  94  cases  flexion  was  present;  in  50  from  a  slight  degree  to  135 
degrees;  in  16  from  135  degrees  to  90;  in  28  to  a  right  angle  or  less. 
Together  with  the  flexion  were  combined  other  deformities  as  fol- 


FiG.  328. — Flexion  deformity  at  the  knee-joint,  with  slight  subluxation  of  the  tibia. 

lows:  Genu  valgum  in  60  cases;  moderate  in  42;  extreme  in  18. 
Genu  varum  in  1  case.  Subluxation  of  the  tibia  in  20  cases.  Out- 
ward rotation  of  the  tibia  in  10  cases. 

As  has  been  stated,  the  primary  deformity  of  knee  disease  is 
simple  flexion.    If  the  disease  is  of  an  acute  type  this  flexion  increases 


Fig.  329. — After  forcible  correction,  showing  the  increase  of  the  posterior  dis- 
placement. Drawing  from  the  a;-ray  photographs  of  an  actual  case  in  which  the  limb 
had  been  corrected  by  direct  force  in  the  ordinary  manner.  See  reverse  leverage, 
Fig.  331. 

rapidly.  If  it  is  subacute  in  character,  or  if  the  disease  is  primarily 
of  the  synovial  membrane,  the  progress  of  the  deformity  is  slow. 
In  ordinary  cases  secondary  distortions  appear  at  a  later  time  and 
especially  when  the  disease  has  reached  the  destructive  stage;  and 


1  Loc.  cit. 


27 


418  TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 

they  are  most  marked  in  patients  who  have  persistently  used  the 
deformed  Hmb  without  protection. 

Actual  Shortening  and  Actual  Lengthening. — Retardation  of  growth 
is,  of  course,  not  an  early  symptom  of  disease;  in  fact,  actual 
lengthening  of  the  limb,  due  to  the  irritative  effect  of  the  disease, 
is  common.  This  lengthening,  sometimes  to  the  extent  of  an  inch 
or  even  more,  may  persist  throughout  the  entire  course  of  treatment, 
but  after  the  cure  of  the  disease  a  corresponding  retardation  of 
growth  that  will  more  than  equalize  the  length  of  the  limbs  may  be 
expected.  If  the  disease  is  of  the  destructive  type  the  ultimate 
shortening  may  be  considerable;  two  or  more  inches  is  not  unusual. 

Leusden,^  in  33  cases  under  treatment  in  the  clinic  at  Gottingen, 
1896-1898,  found  slight  shortening  in  2,  equality  of  length  in  18, 
lengthening  of  the  femur  on  the  diseased  side  in  13. 

In  116  cases  of  tuberculous  disease  of  the  knee  the  limbs  were 
measured  by  Berry  and  Gibney-  with  reference  to  this  point.  In  72 
of  these  there  was  actual  lengthening  of  the  femur,  from  which  it  may 
be  inferred  that  in  at  least  26  per  cent,  of  the  cases  examined  the 
primary  disease  was  of  the  femur. 

In  17 i  inch. 

In  34 i     " 

In  15 f  " 

In  6 1   " 

72  =  62  per  cent. 

In  a  total  of  106  apparently  cured  cases  treated  at  the  New  York 
Orthopedic  Hospital  the  limb  was  lengthened  in  10,  there  was  less 
than  one  inch  of  shortening  in  73,  less  than  two  inches  in  7,  and  more 
than  two  inches  in  14.^ 

H.  L.  Taylor,^  from  an  examination  of  40  cases  of  tuberculous 
disease  of  the  knee,  concludes  that  the  limb  is  almost  always  longer 
in  the  first  two  years  of  the  disease,  usually  longer  during  the  second 
two  years,  but  usually  shorter  when  the  period  of  growth  is  com- 
pleted.    The  lengthening  is  in  most  instances  of  the  femur. 

Diagnosis. — Tuberculous  disease  is  a  local  destructive  process 
that  is,  as  a  rule,  confined  to  a  single  joint.  This  is  an  important 
point  in  the  differential  diagnosis  from  general  or  constitutional 
affections  like  rheumatism,  arthritis  deformans,  and  the  like,  in 
which  several  joints  are  involved.  The  following  affections  may  be 
considered  in  differential  diagnosis. 

Injury  of  the  Knee. — Strains  of  the  knee  in  childhood  are  often 
followed  by  limp  and  by  persistent  flexion  and  pain.  In  such 
cases  the  onset  is  sudden  and  the  symptoms  usually  disappear 
quickly  under  treatment.     Synovitis  of  traumatic  origin  is  usually 

1  Deutsch.  Ztschr.  f.  Chir.,  Band  li,  Heft  3  und  4. 

2  Am.  Jour.  Med.  Sc,  October,  1893. 

3  Humphries  and  Durham:  Jour.  Am.  Med.  Assn.,  January  27,  1917. 
*  Tr.  Am.  Orthop.  Assn.,  1901,  xiv. 


DIAGNOSIS  419 

indicative  of  a  more  severe  injury.  If  it  persists  the  diagnosis  may 
be  doubtful  because  tuberculous  infection  may  have  followed  the 
original  injury.  This  emphasizes  the  importance  of  the  careful 
treatment  and  continued  observation  of  injuries  of  this  class,  especi- 
ally in  weak  children. 

Synovitis. — Chronic  synovitis  of  doubtful  origin,  which  shows  no 
tendency  toward  recovery,  is  in  childhood  almost  always  tuberculous 
in  character. 

Hemarthrosis. — Effusion  of  blood  into  the  knee-joint  may  cause 
inflammatpry  symptoms  during  the  stage  of  absorption  and  organi- 
zation of  the  clot  that  resemble  those  of  disease.  The  sudden  onset 
and  the  personal  history  of  the  patient,  who  may  be  known  as  a 
bleeder,  will  explain  the  symptoms. 

Infectious  Arthritis. — This  is  of  sudden  onset,  attended  by  the 
constitutional  and  local  symptoms  of  acute  infection. 

"Rheumatism." — This,  in  early  childhood,  may  be  confined  to  a 
single  joint,  but  it  is  of  sudden  onset,  it  is  usually  accompanied  by 
constitutional  disturbance,  and  after  a  time  other  joints  become 
involved. 

Arthritis  Deformans. — Diseases  of  this  character,  of  the  mon- 
articular form,  are  more  common  in  adult  life.  The  symptoms  are 
rather  of  the  rheumatic  than  of  the  tuberculous  type. 

Syphilis." — The  later  manifestations  of  syphilis  in  adults  may 
resemble  somewhat  those  of  tuberculosis,  but  they  are  rarely  con- 
fined to  a  single  joint. 

Charcot's  Disease. — Charcot's  disease  of  the  knee-joint  is  char- 
acterized by  sudden  effusion,  by  rapid  destruction  of  the  joint,  and 
consequently  by  weakness  and  deformity;  but  pain  is  usually  very 
slight  and  muscular  spasm  is  absent.  The  diagnosis  of  disease  of 
the  spinal  cord  will  indicate  the  nature  of  the  local  process  of  the 
joint. 

Sarcoma. — Sarcoma,  beginning  at  or  near  the  extremity  of  the 
femur  or  of  the  tibia,  may  simulate  tuberculous  disease  very  closely. 
If  the  tumor  is  of  the  periosteal  type,  it  usually  forms  a  more 
localized  and  irregular  swelling  than  could  be  accounted  for  by 
tuberculous  disease.  Central  sarcoma  may  simulate  tuberculous 
disease  also,  but  the  progress  of  the  tumor  is  more  rapid.  The 
clinical  distinction  between  the  two  is  that  tuberculous  disease  is 
very  amenable  to  treatment  so  far  as  its  symptoms  are  concerned, 
while  the  progress  of  sarcoma  is  but  little  influenced  by  treatment. 
It  may  be  stated,  however,  that  the  a;-rays  are  the  only  means  of  early 
diagnosis,  the  destruction  of  the  'ubstance  of  the  bone  about  the 
tumor  being  much  greater  than  that  caused  by  the  tuberculous 
process. 

Hysterical  Joint. — Some  of  the  symptoms  of  disease  may  be 
simulated  by  hysterical  subjects,  but  there  is  always  an  absence  of 
the  positive  physical  signs  that  invariably  accompany  a  destructive 


420  TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 

disease.     These  and  other  affections  are  described  at  length  in  the 
following  chapters. 

Treatment. — The  treatment  of  tuberculous  disease  of  the  knee 
in  childhood  should  be  conservative,  operative  intervention  being 
simply  incidental  to  protective  treatment.  In  adult  life,  on  the 
other  hand,  the  radical  removal  of  the  disease  may  be  indicated  as 
a  primary  measure.  The  reasons  for  this  distinction  are  obvious. 
In  childhood  the  duration  of  treatment  is  of  no  particular  impor- 
tance as  compared  with  the  final  functional  result,  but  in  adult  life 
the  shortening  of  the  period  of  disability  and  the  definite  assm-ance 
of  cure  may  be  of  far  greater  moment  than  the  preservation  of 
motion. 

In  childhood,  under  favorable  conditions,  ultimate  recovery,  with 
fair  functional  use  of  the  joint,  may  be  anticipated;  while  a  radical 
operation,  although  it  may  cure  the  patient  in  a  shorter  time,  takes 
away  the  possibility  of  a  cure  with  motion.  In  adult  life  a  rigid 
limb  is  a  strong  and  useful  support,  but  in  childhood  the  removal  of 
portions  of  the  epiphyses  and  of  the  epiphyseal  cartilages  entails  a 
progressive  inequality  in  the  limbs,  due  to  loss  of  growth;  further- 
more, miless  the  limb  is  protected  by  mechanical  means  deformity 
is  the  rule,  e^'en  though  the  disease  has  been  thoroughly  removed. 
Thus  the  treatment  of  routine  is,  in  childhood,  at  least,  protection; 
protection  from  the  traumatism  of  motion,  from  the  shock  of  impact 
with  the  ground,  and  from  the  pressure  of  muscular  spasm  and 
contraction. 

Fixation  of  the  joint,  which  is  so  difficult  to  assure  at  the  hip, 
is  easily  attained  at  the  knee,  and,  as  has  been  stated,  the  results 
are  correspondingly  better.  At  the  hip-joint  one  of  the  most 
common  causes  of  shortening  and  deformity  is  upward  displacement 
of  the  femur  upon  the  pelvis,  but  at  the  knee,  if  the  limb  is  supported 
in  the  attitude  of  extension,  the  apposition  of  the  broad  surfaces  of 
the  femm*  and  the  tibia  prevents  displacement,  while  muscular  spasm, 
a  symptom  whose  intensity  is  in  proportion  to  the  degree  of  harmful 
motion  that  is  premitted,  is  easily  controlled. 

Reduction  of  Deformity. — The  first  step  in  treatment  is  the  reduc- 
tion of  deformity  that  may  be  present,  and  as  the  chief  function  of 
the  leg  is  to  support  weight,  the  proper  attitude  in  which  to  fix  the 
limb  is  complete  extension.  Whatever  motion  the  patient  retains 
will  then  be  about  the  point  of  greatest  usefulness.  In  the  cases  in 
which  an  opportunity  for  reasonably  early  treatment  is  offered  the 
only  deformity  is  flexion  induced  by  muscular  contraction.  In  this 
class  of  cases  the  spasm,  and  consequently  the  deformity,  may  be 
readily  overcome  by  placing  the  joint  at  rest. 

The  Plaster  Splint. — The  most  efficient  splint  for  this  preliminary 
treatment  is  a  close-fitting  plaster  support,  applied  from  the  groin 
to  the  ankle,  or  better,  to  include  the  pelvis  and  the  foot,  to  prevent 
edema  of  the  unsupported  part,  which  is  common  after  the  first 


TREATMENT  421 

dressing  and  until  the  circulation  of  the  limb  has  become  adapted 
to  the  new  conditions.  In  the  application  of  the  bandage  the  bony 
prominences  of  the  knee  and  ankle  are  protected  by  cotton..  A 
cotton  flannel  bandage  is  then  applied  smoothly,  and  directly  upon 
this  the  light  plaster  bandage.  At  the  second  application,  at  the 
end  of  a  week,  the  subsidence  of  the  spasm  will  permit  the  straight- 
ening of  the  limb.  In  cases  of  longer  standing  several  successive 
applications  of  the  bandage  may  be  required,  together  with  manual 
extension  during  the  application;  or  an  anesthetic  may  be  admin- 
istered. Under  anesthesia  the  muscular  spasm  relaxes  and  deform- 
ity, even  of  some  standing,  may  be  reduced  by  traction  and  by  slight 
leverage,  the  head  of  the  tibia  being  supported  and  drawn  forward 
by  the  hands  as  the  deformity  is  gently  reduced. 

Traction. — Deformity  may  be  reduced  also  by  traction  with  the 
weight  and  pulley,  the  leg  being  supported  so  that  no  direct  leverage 
is  exerted  at  the  seat  of  the  disease  (Fig.  330) . 


Fig.  330. — Traction  and  counter-traction  in   disease   of  the  knee-joint.      (Marsh.) 

Forcible  Correction  by  Reverse  Leverage. — In  the  more  resistant 
cases,  especially  if  accompanied  by  subluxation,  the  following 
method  may  be  employed. 

The  patient  is  anesthetized  and  is  placed  face  downward  on  a 
table,  the  feet  projecting  over  its  end.  The  body  of  the  patient 
is  then  elevated  by  means  of  pillows  to  conform  to  the  deformity — 
that  is,  the  thigh  is  raised  sufficiently  to  permit  the  tibia  to  lie 
evenly  upon  its  anterior  border  on  the  table.  The  operator  then 
holds  the  head  of  the  tibia  firmly  against  the  table  while  the  assistant 
exerts  intermittent  and  gradually  increasing  downward  pressure  on 
the  thigh,  but  never  to  the  extent  to  lift  the  tibia  from  the  table; 
thus,  further  subluxation  is  impossible.  As  the  contraction  gives 
way  the  pillows  are  removed.  Usually  the  deformity  may  be 
reduced  at  one  sitting,  but  if  it  is  very  resistant  complete  correction 
is  not  attempted.  At  the  conclusion  of  the  operation  adhesive 
plaster  straps  for  traction  and  a  close-fitting  plaster  bandage  are 
applied  (Fig.  331). 

Rest  in  bed  with  traction  is  enforced  for  a  time,  and  the  ordinary 
brace  is  then  applied.  This  is,  in  the  author's  experience,  the  most 
effective  and  satisfactory  method  for  reducing  deformity.     If  the 


422  TUBERCULOUS  DISEASE  OF   THE  KXEE-JOINT 

contraction  is  of  long  standing  preliminary  open  division  of  the 
flexor  tendons  is  advisable.  The  deformity  is  then  in  part  corrected, 
complete  rectification  being  deferred  until  repair  is  complete. 


Fig.  331. — iThe  author's  method  of  correcting  flexion  deformity  at  the  knee  by 
reverse  leverage.  The  folded  sheet  indicates  the  degree  of  subluxation  present.  In 
resistant  cases  of  this  tj-pe  an  assistant  applies  the  pressure  on  the  thigh. 


Fig.  332. — Tuberculous  disease  of  the  knee  in  an  adult,  with  the  form  of  Billroth 
splint  used  at  the  Hospital  for  Ruptured  and  Crippled. 

The  Billroth  Splint. — The  Billroth  splint,  as  modified  by  Stillman, 
is  an  eftective  appliance  for  overcoming  resistant  deformity.  A 
thick  pad  of  felt  is  placed  over  the  upper  surface  of  the  condyles  of 


Treatment 


42S 


the  femur  and  a  thinner  pad  in  the  popHteal  region  over  the  upper 

border  of  the  tibia.     Other  points  that  may  be  subjected  to  pressure 

are  similarly  protected,  especially  the  dorsum  of  the  foot  and  the 

perineum.     A  plaster  bandage  is  then  applied  from  the  groin  to  the 

toes,  made  especially  thick  and  strong  in  the  popliteal  region.     On 

either  side  of  the  knee  two  curved,  slotted  steel  bars  attached  to 

expanded  tin  splints  and  joined  to  one  another  by  an  adjustable 

bolt  are  incorporated  in  it  (Fig.  332).     When  the  bandage  hardens 

it   is   completely   divided    into   two 

parts  by  a   circular  cut  about  the 

knee,  and  the  bolts  in  the  slots  are 

so   adjusted    as    to    form    a   hinged 

splint,   the   centre   of  motion  being 

somewhat  above  and  in  front  of  the 

knee-joint.     When  the  limb  is  slightly 

extended  the  position  of  the  hinges 

has  a  tendency  to  lift  the  tibia  and  to 

separate   it  from   the    femur.     This 

straightening  opens   the    cut   in  the 

popliteal  region,  which  is  held  open 

by  a  wedge  of  cork.     In  this  manner, 

by  the  insertion  of  larger  wedges  the 

limb  is  gradually  straightened  from 

day  to  day   until   the  deformity   is 

overcome,  or  until  a  new  bandage  is 

required.     If    the    pressure    on    the 

front  of  the  femur,  when  the  leverage 

is  exerted,   becomes  painful,  a  part 

of  the  padding  is  removed. 

In  the  treatment  of  older  subjects 
greater  force  may  be  employed  by 
means  of  osteoclasts.  One  of  the 
best  machines  of  this  type  is  the 
Bradford-Goldthwait  genuclast  (Fig. 
333).  The  more  violent  methods 
should  not  be  employed  during  the 
active  stages  of  the  disease ;  and  when- 
ever considerable  force  is  required  in 

young  subjects  the  possibility  of  separating  the  epiphysis  of  the 
femur,  forcing  it  backward  and  thus  pressing  upon  the  popliteal 
vessels,  should  be  borne  in  mind.  In  fact  in  all  cases  in  which 
deformity  has  been  corrected  one  should  assure  oneself  by  subse- 
quent examination  that  the  circulation  of  the  extremity  is  not 
impaired. 

Mechanical  Treatment. — The  most  efficient  mechanical  appliance 
for  the  treatment  of  tuberculous  disease  during  the  acute  stage  at 
the  knee  is  the  Thomas  knee  hrcuce.     This  consists  of  two  lateral 


Fig.  333.— The  Bradford-Gold- 
thwait genuclast  for  the  correc- 
tion of  flexion  deformity  and  sub- 
luxation at  the  knee.  Counter- 
pressure  is  applied  over  the  lower 
extremity  of  the  femur.  Subluxa- 
tion is  prevented  during  the  for- 
cible correction  by  means  of  the 
screw  and  strap  beneath  the  head 
of  the  tibia,  by  which  it  is  drawn 
forward. 


424 


TUBERCULOUS  DISEASE  OF   THE  KXEE- JOINT 


uprights  which  support  the  limb  on  either  side,  terminating  below 
the  foot  in  a  crossbar  shod  with  leather  or  rubber,  which  serves  as  a 
stilt,  and  above  in  a  ring  that  fits  the  upper  extremity  of  the  thigh, 
and  supports  the  weight  of  the  body.  The  brace  is  made  of  iron 
wire  from  three-sixteenths  to  three-eighths  of  an  inch  in  thickness. 
The  ring  is  of  an  irregular  ovoid  shape,  flattened  in  front,  expanded 
behind  and  wider  on  the  inner  than  on  the  outer  side  (Fig.  334). 
This  ring  is  welded  to  the  uprights  at  a  lateral  and  anteroposterior 
inclination.     The  lateral  inclination  forms  an  angle  with  the  inner 


Fig.  334.— The  Thomas  knee 
splint,  showing  the  inner  bar  B  placed 
farther  to  the  front  than  the  outer 
bar  C;  ^4.  is  the  lowest  part  of  the  ring: 
upon  this  rests  the  tuberosity  of  the 
ischium. 


Fig.  335. — The  ring  of  the  Thomas  knee 
splint  after  padding.      (Ridlon.) 


bar  of  135  degrees  (Fig.  336),  the  anteroposterior  inclination  forms 
an  anterior  angle  of  145  degrees  (Fig.  334)  with  the  same  upright, 
which  is  set  upon  the  ring  at  a  point  slightly  in  advance  of  its  fellow. 
The  objects  of  the  shape  of  the  ring  and  of  its  inclination  are  these: 
its  anterior  part  is  flattened  to  conform  to  the  surface  of  the  groin; 
its  posterior  segment  is  expanded  to  accommodate  the  thickness  of 
the  buttock;  the  anteroposterior  inclination  adjusts  it  to  the  tuber- 
osity of  the  ischium.  The  lateral  inclination  follows  the  line  of 
Poupart's  ligament  from  the  inner  to  the  outer  bar,  which  in  order 


TREATMENT 


425 


to  assure  better  support  and  less  pressure,  rises  above  the  level  of 
the  trochanter  major. 

The  ring  is  made  somewhat  larger  than  the  thigh  to  allow  for 
padding  with  felt.  This  should  be  thicker  on  the  inner  and  pos- 
terior surface,  where  the  weight  is  borne,  than  on  the  anterior  and 
outer  part.  The  padded  ring  is  then  smoothly  covered  with  basil 
leather.  As  used  at  the  Hospital  for  Ruptured  and  Crippled,  in  the 
treatment  of  sensitive  or  progressive  cases,  the  brace  is  made  from 
two  to  three  inches  longer  than  the  leg,  to  serve  as  a  stilt  like  the  hip 
splint.  To  the  foot-piece  two  straps  are  attached  on  either  side  to 
provide  for  traction  on  the  limb  and  to  hold  the  brace  securely  in 


Fig. 


336. — Thomas  knee  splint.    Show- 
ing the  front  of  the  ring. 


Fig.  337. — Showing    the    back    of    the 
ring.      (Ridlon.) 


its  place.  A  band  of  leather  is  drawn  between  the  bars  at  the  upper 
third  and  another  at  the  lower  third  of  the  brace  to  serve  as  supports 
for  the  thigh  and  calf.  Adhesive  plasters,  reaching  from  the  knee 
to  the  ankle,  provided  with  buckles  above  the  malleoli,  having  been 
applied,  the  ring  is  pushed  firmly  against  the  perineum  and  is  held 
in  position  by  buckling  the  straps  to  the  traction  plasters  with  as 
much  tension  as  the  comfort  of  the  patient  will  permit.  The  thigh 
and  leg  supports  should  fit  the  parts  perfectly;  the  knee  is  then 
fixed  in  its  place  by  a  bandage  drawn  about  it  and  the  lateral  bars. 
Ankle  and  heel  straps  complete  the  adjustment  (Fig  338). 

In  cases  in  which  the  joint  is  very  sensitive  and  in  which  there  is 
a  tendency  to  deformity  the  entire  limb  is  in  addition  enclosed  in  a 


426 


TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 


light  plaster  bandage,   so-called   "skin  fitting,"   applied  directly 
upon  a  cotton  flannel  bandage. 

If  the  brace  is  attached  by  means  of  the  adhesive  plaster  straps,  a 
certain  degree  of  traction  is  assured,  together  with  additional  accu- 
racy of  adjustment;  and  by  the  traction  and  by  the  direct  pressure 
on  the  knee  the  slighter  degrees  of  deformity  may  be  reduced  without 
discomfort.     In  acute  cases  preliminary  rest  in  bed  is  advisable, 

and  crutches  may  be  employed  in 
the  early  stages  of  ambulatory  treat- 
ment. But  during  the  greater  part 
of  the  active  stages  of  the  disease  the 
brace  serves  as  a  perineal  crutch  and 
by  the  use  of  bandage  pressure  from 
before  backward,  or  toward  one  or  the 
other  upright,  flexion  or  lateral  distor- 
tion of  the  limb  may  be  corrected 
during  the  course  of  treatment.  This 
brace  may  be  used  in  the  treatment 
of  very  young  children  if  it  is  care- 
fully fitted  and  if  the  parts  are  kept 
clean  and  dry,  and  it  is  an  effective 
brace  for  all  ages,  and  for  all  condi- 
tions of  disease. 

The  Caliper  Brace. — The  traction 
may  be  discarded  and  the  brace  may 
be  held  in  position  by  a  shoulder 
band,  or  it  may  be  used  as  a  so-called 
caliper  splint.  In  this  form  it  was 
almost  exclusively  employed  by  Mr. 
Thomas  in  his  later  practice  and  at 
the  present  time  by  Ridlon,^  the  long 
brace  being  used  simply  for  a  bed 
splint.  As  a  caliper  brace  the  two 
bars  are  cut  off,  turned  directly  in- 
ward at  a  right  angle,  and  are  inserted 
into  a  steel  tube,  which  is  passed 
through  the  heel  of  the  shoe.  The 
bars  are  made  slightly  longer  than 
the  limb,  so  that  the  patient's  heel 
is  lifted  nearly  an  inch  from  the  inside  of  the  shoe  when  walking; 
thus,  the  jar  of  impact  with  the  ground  is  prevented.  The  brace 
is  fixed  in  position  by  a  leather  band  beneath  the  knee  and  another 
beneath  the  calf,  and  the  limb  is  held  extended  by  pressure  pads 
applied  to  the  thigh  and  leg,  as  illustrated  (Fig.  339).  Ridlon  uses 
the  brace  to  reduce  deformity  by  direct  pressure  backward  on  the 
knee  by  means  of  bandages,  opiates  being  given  to  relieve  pain. 

\ 

1  Tr.  Am.  Orthop.  Assn.,  vi. 


Fig.  338. 


-The  Thomas  knee 
brace. 


TREATMENT 


427 


I 


\ 


Other  braces  may  be  employed,  for  example,  the  traction  hip 
brace,  but  as  the  Thomas  brace  answers  every  requirement,  it 
seems  unnecessary  to  describe  others  in  this 
connection.  The  plaster  splint  is  an  unsatis- 
factory support  in  the  treatment  of  children 
because  it  does  not  hold  its  place  securely. 
To  make  it  effective  as  a  splint  it  must  either 
include  the  pelvis  or  the  foot.  It  is  therefore 
unsuitable  as  a  routine  appliance.  When  the 
disease  isi  no  longer  active  weight-bearing  is 
permitted,  but  splinting  of  the  joint  is  con- 
tinued until  the  disease  is  practically  cured. 
For  this  purpose  a  light  brace  with  two  lateral 
uprights  may  be  used. 

Accessory  Treatment. — The  accessories  to 
protective  treatment,  which,  of  course,  in- 
cludes the  proper  attention  to  the  general 
condition  of  the  patient,  are  local  applica- 
tions, injections,  and  venous  stasis.  They  are 
classed  as  accessories  because  none  of  them 
is  essential  to  successful  treatment. 

The  local  application  of  cautery,  applied  at 
intervals  of  a  week,  or  less,  may  add  to  the 
comfort  of  the  patient  and  stimulate  the  rep- 
arative processes.  The  x-rays  appear  to  act 
in  a  somewhat  similar  manner;  they  relieve 
pain,  and  in  most  instances  the  infiltration 
of  the  tissues  becomes  less  marked. 

Ichthyol  ointment  of  a  strength  of  about 
40  per  cent,  relieves  pain  and  local  conges- 
tion in  certain  instances.  Firm  compression 
by  means  of  a  flannel  bandage  or  by  the  ad- 
hesive plaster  strapping  is  of  value,  especially 
in  the  infiltrating,  "boggy"  type  of  disease. 
The  knee  is  the  joint  into  which  injections 
may  be  made  most  easily.  Such  injections  are 
more  likely  to  be  of  service  in  the  synovial 
than  in  the  osteal  type  of  disease.  (See  page 
265.) 

Bier's  treatment  by  passive  congestion  may 
be  easily  applied  and  its  effects  should  be 
tested.  The  limb  up  to  the  joint  is  firmly 
bandaged  by  a  flannel  bandage.  A  rubber 
band  is  then  applied  immediately  above  the 
joint  with  sufficient  tension  to  retard  the 
retm-n  of  the  venous  blood.  The  joint  then 
becomes  swollen  and  congested.      The  con- 


FiG.  339.— The  cali- 
per. E,  the  ring  around 
the  upper  part  of  the 
thigh.  A,  pad  for  back- 
ward pressure.  B,  ban- 
dage. C,  bandage.  F, 
leather  sling  for  sup- 
port at  the  back  of  the 
limb.  D,  a  strip  of 
bandage  fastening  to- 
gether the  pressure  pads 
to  prevent  slipping  and 
consequent  loss  of  pres- 
sure. (Ridlon  and 
Jones.) 


428  TUBERCULOUS  DISEASE  OF   THE  KXEE-JOINT 

gestion  is  applied  for  an  hour  or  more  at  a  time,  once  or  twice  daily. 
Passive  congestion  apparenth'  increases  the  stability  of  the  gran- 
ulation tissue  and  its  further  transformation  to  fibrous  tissue.  (See 
page  267.) 

Treatment  during  Convalescence.^ — During  the  active  stage  of  the 
disease  the  brace  must  be  worn  day  and  night.  During  the  stage 
of  recovery  it  may  be  used  as  a  caliper  and  finally  shortened  so  that 
the  limb  may  support  weight  and  may  be  removed  at  night  to  per- 
mit motion  at  the  knee.  Later  a  form  of  walking  brace  (Fig.  2.35) 
permitting  limited  motion  at  the  knee  may  of  be  service;  but  this 
is  not  an  essential  in  treatment.  If  slight  knock-knee  persists  after 
recovery,  it  may  be  overcome  by  the  use  of  a  Thomas  knock-knee 
brace,  which  will  also  serve  as  a  protection  to  the  weak  joint.  The 
indications  of  cure  have  been  discussed  under  hip  disease.  In 
brief,  when  sufficient  time  has  elapsed  to  permit  of  natural  cure; 
when  there  have  been  no  sjinptoms  of  active  disease  for  months; 
when  muscular  spasm  has  disappeared,  one  may  tentatively  remove 
the  brace  in  the  manner  described.  But  any  symptom  of  disease, 
and  particularly  increasing  limitation  of  the  range  of  motion,  or  a 
tendency  toward  deformity,  which  resists  the  manipulative  correc- 
tion that  must  always  be  employed  in  the  after-treatment  of  stiff- 
ened joints,  indicates  the  necessity  for  continued  protection.  If 
anchylosis  is  present,  supervision  and  occasional  corrective  treat- 
ment are  usually  required  during  the  period  of  growth  to  assure 
final  symmetry. 

Complications. — Extra-articular  Disease. — In  certain  cases,  especi- 
ally in  young  children,  the  disease  about  the  epiphyseal  cartilage  of 
the  femur  or  of  the  tibia  may  find  its  way  to  the  exterior  before  it 
invades  the  joint.  This  fortunate  course  is  indicated  by  local 
sensitiveness  and  swelling  over  one  of  the  condyles  of  the  femur  or 
about  the  head  of  the  tibia.  In  such  instances  the  thorough  removal 
of  the  disease  is  indicated,  or  if  a  Roentgen  picture  shows  that  the 
disease  is  accessible  even  though  it  is  not  immediately  below  the 
surface,  an  exploratory  operation  may  be  advisable.  An  incision 
is  made,  usually  over  the  internal  condyle  of  the  femur.  The 
periosteum  is  raised  and  a  portion  of  the  cortex  is  removed  in 
order  to  expose  the  spongy  bone  on  either  side  of  the  epiphyseal 
cartilage. 

In  many  instances  an  area  of  softening  will  be  found.  This  must 
be  thoroughly  removed.  The  cavity  may  be  treated  with  pure 
carbolic  acid  or  the  cautery,  or  filled  with  iodoform  emulsion  and 
the  wound  is  then  closed.  In  favorable  cases  prompt  operative 
intervention  may  cut  short  the  course  of  the  disease. 

Abscess. — Abscess  is  present  as  a  complication  in  about  one-third 
of  the  cases  that  have  received  efficient  protection,  and  in  a  larger 
percentage  of  those  in  which  treatment  has  been  neglected. 


COMPLICATIONS  429 

It  was  present  in  51  per  cent,  of  Konig's  cases^  and  in  47  per 
cent,  of  300  final  results  reported  by  Gibney.^  At  the  knee,  as  at 
other  joints,  the  infected  abscess  is  the  most  dangerous  complica- 
tion of  the  diesase,  as  is  illustrated  by  Konig's  statistics : 

Death-rate  in  cases  without  abscess 25  per  cent. 

Death-rate  in  cases  with  abscess 46  " 

Although  in  many  instances  abscess  indicates  an  extensive  and 
destructive  disease  of  the  bone,  yet  the  exhausting  suppuration  that 
is  an  indirect  cause  of  death  is  suppuration  from  infected  areas  in 
the  thigh  and  leg,  which  may  have  little  direct  relation  to  the  extent 
of  the  original  disease.  It  should  be  the  aim  in  treatment  to  prevent 
this  burrowing  of  fluid  after  the  capsule  has  been  perforated,  and 
to  prevent  overdistention  of  the  capsule,  even  in  order  to  lessen  the 
macerating  effect  of  the  tuberculous  fluid  upon  the  cartilages. 
When  the  fluid  within  the  joint  is  of  considerable  amount,  and  when 
it  is  increasing  in  quantity,  it  may  be  removed  by  aspiration,  or  a 
better  procedure  is  to  incise  the  capsule.  This  will  permit  thor- 
ough removal  of  its  fluid  and  solid  contents,  after  which  the  opening 
may  be  closed  with  sutures. 

Tuberculous  abscess  which  has  perforated  the  capsule  may  be 
treated  in  the  same  manner,  or  it  may  be  drained  subsequently, 
according  to  the  indications.  Unless  the  abscess  is  infected  careful 
bandaging  of  the  thigh  and  leg  should  prevent  burrowing. 

Synovial  Tuberculosis. — In  the  forms  of  synovial  tuberculosis 
that  resemble  chronic  synovitis  the  fluid,  if  the  quantity  is  large, 
may  be  evacuated  by  an  incision  in  the  capsule.  This  should  be 
of  sufficient  size  for  inspection — masses  of  fibrin  and  hypertrophied 
and  diseased  tissue  should  be  removed.  Afterward  the  interior  of 
the  joint  may  be  treated  with  an  application  of  a  strong  solution  of 
chloride  of  zinc  or  pure  carbolic  acid.  The  wound  should  then  be 
closed  and  a  plaster  support  should  be  applied.  By  the  operative 
treatment  repair  is  stimulated  and  adhesions  form  which  lessen  the 
capacity  of  the  capsule.  Later  a  protective  brace  should  be  worn  to 
guard  the  joint  from  sudden  twists  and  strains  and  to  limit  the  range 
of  motion  within  the  painless  arc  (Fig.  207).  The  adhesive-plaster 
strapping  may  be  employed  in  cases  of  this  class  with  great  advan- 
tage. It  is  in  this  type  of  disease  that  passive  congestion  is  most 
effective.  The  same  is  true  of  the  injection  of  iodoform  emulsion 
or  other  remedies  of  this  class.  Theoretically,  such  treatment 
should  hasten  repair,  should  modify  the  infectious  quality  of  the 
tuberculous  fluid  and  lessen  the  danger  of  infection  with  pyogenic 
germs. 

1  Loc.  cit.  2  Am  Jour.  Med.  Sc,  October,  1893. 


430  TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 

Operative  Intervention. — Arthrectomy. — ^\Yhen,  as  in  exceptional 
cases,  the  disease  is  progressive  and  shows  no  tendency  toward 
recovery,  and  particularly  if  an  infected  abscess  communicating 
with  the  joint  makes  efficient  drainage  difficult,  the  operation  of 
arthrectomy  may  be  indicated. 

An  Esmarch  bandage  having  been  applied,  the  joint  is  thoroughly 
exposed  by  lateral  incision  or  by  an  anterior  incision  passing  below 
the  patella,  and  all  the  diseased  tissue  is  removed;  that  in  the  soft 
parts  is  cut  away,  and  foci  in  the  bone  are  excavated  with  the  chisel 
and  scoop.  If  infection  be  present  the  joint  may  be  packed  with 
gaiize,  the  leg  being  fixed  in  the  position  of  flexion;  but  in  other 
instances  the  wound  is  closed  with  or  without  drainage  as  may  seem 
advisable.  In  a  large  proportion  of  cases  primary  healing  may  be 
obtained.  By  the  procedure  one  may  hope  to  hasten  repair  by 
removing  the  products  of  the  disease,  but  in  all  but  exceptional  cases 
the  functional  result  will  be  anchylosis.  The  operation  has  the 
advantage  over  complete  excision  in  that  less  bone  is  removed,  and 
that  the  epiphyses,  in  part,  at  least,  remain;  thus  the  immediate 
as  well  as  the  ultimate  shortening  is  less  than  after  excision. 

Results  of  Arthrectomy. — The  direct  death-rate  of  the  opera- 
tion is  small.  In  150  cases  reported  by  Konig  but  3  deaths  were 
attributed  to  the  operation  itself.  The  final  results  in  114  of  these 
cases,  in  which  the  operation  was  performed  in  childhood,  were  as 
follows : 

Patients  cured  and  living 90 

Cured  of  the  local  disease,  but  not  li\ang  at  the  time 

of  the  investigation 10 

Practically  cured,  insignificant  fistulse  remaining     .  2 

102  =89.5  per  cent. 

Living,  not  cured 5 

Deaths  before  the  cure  of  the  local  disease  ...  7 

12   =  10.5  per  cent. 

Thus  in  89  per  cent,  of  the  cases  the  operation  was  successful  as 
far  as  the  cure  of  the  local  disease  was  concerned.  In  75  per  cent, 
of  the  successful  cases  immediate  cure  was  attained;  in  25  per  cent, 
fistulse  persisted  for  a  longer  or  shorter  time.  In  10  cases  some 
motion  was  retained,  but  in  others  anchylosis  followed  the  opera- 
tion. In  about  70  per  cent,  of  the  cases  the  limb  was  practically 
straight;  in  30  per  cent,  it  was  distorted.  This  shows  the  necessity 
of  continued  supervision  and  in  many  instances  of  protective  treat- 
ment during  the  growing  period  in  all  cases  m  which  anchylosis  is 
present  from  whatever  cause. 

In  48  cases  in  which  the  operation  had  been  performed  before  the 
tenth  year,  and  in  which  the  limbs  were  straight,  the  influence  of 
the  operation  on  the  growth  was  investigated. 


OPERATIVE  INTERVENTION 


431 


Number  of  cases 


6 
5 
4 
3 
19 
11 


Years  elapsed 

Av- 

erage shortening 

since  ooeration. 

m  cm. 

.      2 

1.0 

.      3 

1.6 

.     4 

1.0 

.     5 

2.0 

.      6- 

-7 

2.0 

.     8- 

13 

2.5 

These  measurements  indicate  that  the  shortening  is  not  Hkely 
to  be  very  great  as  a  result  of  the  operation,  certainly  very  much 
less  than  after  complete  or  even 
partial  excision  performed  at  the 
same  age. 

Excision.  —  Excision  of  the 
joint  in  childhood  has  been 
practically  abandoned,  because 
of  the  great  shortening  that 
follows  complete  removal  of  the 
epiphyses,  and  because  so-called 
partial  excision — that  is,  the 
removal  of  the  thin  sections  of 
bone  from  the  surfaces  of  the 
femur  and  tibia,  leaving  the  car- 
tilages— is  usually  an  unneces- 
sary operation,  in  the  sense  that 
disease  that  might  be  cured  by 
this  procedure  might  have  been 
cured  by  conservative  methods. 

Early  excision  in  adult  cases 
is  often  indicated  because  it  will 
assure  a  cure  of  the  disease  in 
a  short  time,  whereas  mechan- 
ical treatment  will  at  best  re- 
quire years  of  disability  with  no 

certain  prospect  of  absolute  cure  -^     ^f ."   340.— Deformity  and  shortening 
.     ,^  li-ji  •     ^        TP   iiresulting  trom  excision  of  the   knee   in 

at  the  end   or  the  period,     it,      childhood. 
therefore,   the  disease  has  pro- 
gressed sufficiently  to  indicate  that  the  natural  cure  would  result 
in  anchylosis,  or  if  the  time  required  for  cure  is  of  importance  to 
the  patient,  early  incision  may  be  advised  in  the  case  of  the  adult 
or  adolescent  whose  growth  is  nearly  completed. 

The  operation  is  performed  under  the  Esmarch  bandage,  and  the 
joint  is  exposed  by  the  anterior  incision,  passing  below  the  patella 
as  in  operation  of  arthrectomy.  All  the  diseased  tissues  including 
the  patella  and  the  capsule  are  cut  away  leaving  only  the  skin. 
Sections  of  the  bones,  parallel  to  the  articular  surfaces,  are  removed 
sufficient  in  depth  to  include  all  the  diseased  area.  The  sections 
should  allow  the  bones  to  be  brought  into  close  apposition  and  they 


432  TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 

should  be  fixed  by  strong  sutures  of  catgut  passed  through  the 
anterior  apposed  surfaces  of  the  femur  and  tibia.  The  vessels 
having  been  ligated,  the  wound  may  be  closed  with  or  without 
drainage,  as  may  be  indicated  by  the  character  of  the  disease,  a 
plaster-of-Paris  dressing  is  applied,  and  the  limb  is  raised  to  a  per- 
pendicular position  so  that  the  weight  of  the  leg  may  be  utilized  to 
assure  rest.  Mechanical  protection  should  be  assumed  for  several 
months  until  union  is  secure. 

Results  of  Excision. — In  Konig's  statistics  of  300  excisions, 
6  deaths  were  due  directly  to  the  operation,  and  23  others  occurred 
during  the  course  of  the  after-treatment — a  total  of  29  (9.6  per  cent.). 

In  23  instances  amputation  was  afterward  performed  because  of 
failure  of  the  operation.  The  good  results  are  classed  by  Konig 
as  75  per  cent.,  the  bad  as  25  per  cent.  In  193  cases  the  position 
of  the  limb  in  after  years  was  investigated.  It  was  straight  in  175, 
distorted  in  18,  all  but  1  of  this  latter  group  being  in  children.  Of 
400  resections  of  the  knee  in  Bruns'  clinic  final  results  were  ascer- 
tained in  379  cases.     The  early  results  were  as  follows : 

Discharged,  well 343 

Discharged  with  fistulse .29 

Amputated 17 

Dead 17 

Not  cured 4 

Final  results: 

Well 280  ] 

With  fistulae 3  I  ^      ,          u     ct  n 

Dead,  but  cured  of  local  disease   .       .  45  f  ^°°^  '^'''^^'  ^^"^  P<^"  ^^°*- 

Dead,  not  cured       .       .       .             .       .  3  J 

Living,  not  cured 10  1 

Dead,  not  cured 6     „   j  i^    ,« 

Died  in  clinic ,j.     Bad  results  12  per  cent. 

Amputated 23  J 

Curvature  of  the  limb: 

Straight 27.1  per  cent. 

Moderately  flexed 28.0  " 

Markedly  flexed 44.9  " 

Amputation. — This  operation  is  indicated  as  a  life-saving  measure. 
When  the  disease  is  so  extensive  as  to  require  complete  removal  of 
the  epiphyses  in  early  childhood,  amputation  is  the  preferable 
operation,  as  the  limb,  aside  from  requiring  constant  protection  to 
prevent  deformity,  will  be  so  short  as  to  be  of  little  practical  use. 

Operations  for  the  Relief  of  Final  Deformity. — In  the  majority  of 
the  cases  deformity  can  be  rectified  by  one  of  the  methods  already 
described.  If,  however,  there  is  bony  anchylosis  in  an  attitude  of 
marked  flexion  the  limb  may  be  straightened  by  linear  osteotomy  of 


PROGNOSIS  433 

the  femur  just  above  the  joint,  supplemented  if  the  deformity  is 
extreme  by  a  secondary  osteotomy  of  the  tibia.  If  flexion  deformity 
is  of  long  standing,  division  of  the  hamstring  tendons  is  often 
required.  In  such  cases  the  correction  should  not  be  completed  at 
the  first  operation  but  preferably  at  several  sittings  to  permit  the 
adaptation  of  the  soft  parts  and  the  bloodvessels  to  the  new  attitude. 
Simple  osteotomy  is  to  be  preferred  to  cuneiform  osteotomy  in 
young  subjects,  as  no  bone  is  removed. 

Genu  valgum  may  be  corrected  by  a  similar  operation.  (See 
Osteotomji  for  Knock-knee.) 

In  certain  selected  cases  the  joint  may  be  opened  for  the  purpose  of 
separating  the  bones  and  interposing  flaps  of  fibromuscular  tissue. 
Although  the  prospect  of  restoring  useful  motion,  is  slight,  it  will 
at  least  serve  to  correct  deformity.     (See  Anchylosis.) 


Fig.  341. — Jig-saw  osteotomy,  assuring  security.      (Osgood.) 

Prognosis. — The  most  important  statistical  evidence  on  the 
course  and  the  outcome  of  tuberculous  disease  of  the  knee-joint  in 
childhood  has  been  presented  by  Gibney.  The  statistics  completed 
in  1892  were  the  result  of  an  investigation  of  499  cases  treated  during 
a  period  of  twenty  years,  1868-1887.  In  but  300  of  these  could 
definite  information  be  obtained.^ 

Eighty-seven  per  cent,  of  the  cases  were  in  children,  and  51  per 
cent,  of  the  patients  were  less  than  five  years  of  age  at  the  inception 
of  the  disease. 

The  cases  were  divided  into  three  classes,  according  to  the  treat- 
ment that  had  been  followed: 

1.  The  expectant  treatment.  In  this  class  no  apparatus  had 
been  employed,  or,  if  employed,  it  had  been  inefficient. 

2.  The  fixation  treatment.  In  this  class  the  joint  had  been  more 
or  less  efficiently  splinted,  but  not  protected  from  impact  with  the 
ground. 

1  Am.  Jour.   Med.  Sc,  October,  1893. 
28 


434 


TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 


3.  The  protective  treatment.  In  this  class  the  joint  had  been 
sphnted  and  protected  from  jar,  and  the  mechanical  treatment  had 
been  efficient. 

The  results  were  classified  as  follows: 


Total. 

Excisions. 

Amputations. 

'Deaths. 

Under 
treatment. 

Cured. 

Expectant 

Fixation 

Protection 

71 

190 

39 

5 
9 

0 

- 

3 
1 

0 

3 
35 

2 

9 
31 
11 

51 

114 

26 

300 

14 

4 

40 

51 

191 

Mortality. — ^The  total  deaths  in  the  300  cases  were  40  (13.3  per 
cent.) ;  26  of  these  were  from  causes  directly  or  indirectly  connected 
with  the  disease  (8.6  per  cent.),  viz. : 

Operative  shock          . 1 

Prolonged  suppuration 16 

Tuberculous  meningitis 6 

Phthisis 3 

26 
Intercurrentjdisease 14 

40 

Function. — The  functional  results  as  regards  motion  in  the  cases 
in  which  conservative  treatment  had  been  continued  to  the  end, 
including  the  cases  still  under  observation,  242  of  300,  were  as 
follows : 


Total. 

Motion  retained. 

Anchylosed. 

Expectant 

Fixation 

Protection 

60 

145 

37 

44  or  73  per  cent. 
113  or  77 
34  or  95 

16 

32 

3 

242 

191  or  79  per  cent. 

51 

Of  the  191  patients  who  retained  a  movable  joijit,  74  had  had 
abscesses,  3  or  more  cicatrices  being  present  in  39. 

As  to  the  range  of  motion,  in  74  it  was  from  45  degrees  to  normal 
and  in  41  more  than  90  degrees;  thus  30  per  cent,  of  the  patients 
retained  a  fair  range  of  motion. 

Deformity. — In  51  cases  anchylosis  was  present;  in  16  of  these  the 
limb  was  practically  straight,  in  35  it  was  flexed  more  than  30  degrees 
(69  per  cent.). 

These  statistics  again  illustrate  the  great  tendency  toward  deform- 
ity, when  during  the  growing  period  there  is  anchylosis  at  the  knee 
from  whatever  cause. 


PROGNOSIS  435 

In  the  191  cases  in  which  motion  was  retained  the  hmb  was 
practically  straight  in  125  (65  per  cent.).  In  49  others  the  flexion 
was  less  than  25  degrees,  and  in  but  16  could  the  deformity  be 
classed  as  bad  (8  per  cent.). 

In  10  cases  only  did  relapse  occur  after  apparent  cure. 

In  but  16  of  the  449  cases  was  there  involvement  of  other  joints 
while  the  patients  were  under  observation  (3.2  per  cent.).  In  8 
of  these  the  spine  was  diseased,  in  2  the  hip,  and  in  6,  other  joints. 

Of  106  apparently  final  results  reported  from  the  New  York 
Orthopedic,  Hospital  {loc.  cit).  There  were  39  with  motion  from 
full  extension  to  90  degrees  of  flexion  36,  with  motion  from  full 
extension  to  15  to  90  degrees  of  flexion,  13  with  anchylosis  in  a 
straight  position,  13  with  anchylosis  in  flexion,  and  5  with  flexion 
deformity  without  anchylosis.  The  average  duration  of  treatment 
seven  years.     The  death-rate  was  6.2  per  cent. 

The  influence  of  age  upon  the  death-rate  and  the  ultimate  causes 
of  death  are  iflustrated  by  Konig's  statistics,  the  death-rate  being 
much  higher,  at  least  in  the  cases  in  early  childhood,  than  in  this 
country. 

According  to  Konig's  statistics,  the  death-rate,  direct  and 
indirect,  from  disease  of  the  knee-joint,  was  as  follows : 

323  children  (   1  to  15  years  of  age),  deaths     .  .      .  65  =  20  per  cent. 

225  patients  (16  to  30  years  of  age),  deaths     .  .  61  =  24  per  cent. 

68  patients  (31  to  40  years  of  age),  deaths     .  30  =  44  per  cent. 

74  patients  more  than  40  years  of  age.  deaths  .       .  45  =  60  per  cent. 

Causes  of  Death. 

Deaths  from  causes  not  connected  with  the  disease    .      14   =  2.0  per  cent. 

Deaths  following  operations 18   =  2.5  per  cent. 

Deaths  caused  by  tuberculosis,  141   =22.5  per  cent,  of  all  cases  and  80 
per  cent,  of  all  the  deaths. 

Tuberculosis  of  the  knee 1 

Tuberculosis  of  the  lungs 94 

General  tuberculosis 30 

Tuberculous  meningitis 7 

Acute  miliary  tuberculosis 3 

Tuberculosis  of  other  parts 6 

141 

It  may  be  noted  that  16  of  the  40  deaths  in  Gibney's  cases  were 
due  to  prolonged  suppuration,  and  that  of  51  cases  still  under 
observation  26  had  been  treated  for  ten  years  or  longer,  and  were 
still  uncured.  This  indicates  that  in  a  larger  proportion  of  the  cases 
conservative  methods  should  have  been  supplemented  by  more 
radical  treatment.  Still,  taken  as  a  whole,  the  results,  although 
the  mechanical  treatment  was,  in  many  instances,  far  from  efficient, 
are  much  better  than  any  others  that  have  been  presented. 

On  this  evidence  the  following  conclusions  seem  to  be  justified: 
The  death-rate  in  childhood  from  all  causes  should  be  less  than  10 


436  TUBERCULOUS  DISEASE  OF   THE  KNEE-JOINT 

per  cent.  The  duration  of  treatment  is  from  two  to  ten  years. 
Recovery  with  a  useful  range  of  motion,  if  the  diagnosis  has  been 
made  at  an  early  stage  and  if  efficient  mechanical  treatment  has 
been  employed,  may  be  predicted  in  50  per  cent,  of  the  cases. 

Deformity  can  always  be  prevented  by  treatment  and  by  super- 
vision. Under  favorable  conditions  radical  operations  are  not 
often  indicated,  but  when  indicated  they  should  not  be  delayed  too 
long.  Amputation  of  the  limb  should  prevent  death  from  pro- 
longed suppm-ation.  In  a  certain  proportion  of  cases  the  disease 
may  be  cut  short  by  early  exploratory  operations  for  the  removal  of 
foci  of  disease  in  the  bone  before  the  joint  has  become  involved. 

Although  the  benefits  of  protective  treatment  are  as  evident  in 
disease  of  the  adult  as  in  childhood,  yet  early  operation  is  often 
indicated  in  this  class,  because  of  the  necessity  for  shortening  the 
period  of  disability,  and  because  excision  assm*es  a  straight  and 
useful  limb. 


CHAPTER  X. 

NON-TUBERCULOUS  AFFECTIONS  AND  DEFORMITIES 
OF  THE  KNEE-JOINT. 

STRAINS  AND  INJURIES  OF  THE  KNEE  IN  CHILDHOOD. 

Injury  of  the  knee  in  childhood  may  cause  local  discomfort  and 
persistent  flexion  of  the  leg,  even  when  but  little  synovial  effusion 
is  present.  In  this  class  of  cases  the  application  of  a  plaster  splint, 
under  sufficient  traction  to  overcome  the  deformity,  is  of  service  in 
placing  the  part  at  rest  and  preventing  further  injury.  The  impor- 
tance of  treating  promptly  slight  injuries  of  the  joints  in  childhood, 
especially  in  the  class  of  patients  predisposed  to  tuberculous  infec- 
tion, has  been  mentioned  already  in  the  consideration  of  hip  disease. 

Muscular  "cramp,"  a  form  of  tetanic  contraction,  induced  pos- 
sibly by  injm-y  or  by  a  mild  form  of  arthritis  (toxic),  which  fixes  the 
limb  in  a  flexed  or  extended  position,  is  sometimes  seen  in  chil- 
dren of  a  susceptible  or  nervous  temperament.  The  treatment  is 
similar  to  that  of  strains. 

SYNOVITIS. 

Acute  Synovitis. — The  knee  from  its  size  and  construction  is 
especially  liable  to  injury,  which  if  of  any  severity  js  usually  followed 
by  eftusion  of  fluid  within  the  joint  (synovitis).  Its  symptoms  are 
discomfort,  swelling,  local  heat,  and  limitation  of  motion.  The 
patella  floats  when  30  c.c.  of  fluid  is  contained  in  the  joint,  the 
normal  capacity  being  about  200  c.c. 

Treatment. — Injm-y  and  its  attendant  synovitis  may  be  treated, 
immediately,  by  splints,  by  elevation  of  the  limb,  by  the  application 
of  ice-bags  and  the  like;  but  after  the  acute  symptoms  have  sub- 
sided the  absorption  of  the  effused  fluid  is  aided  by  functional  use 
of  the  limb,  if  the  joint  is  properly  protected.  One  of  the  most 
efficient  methods  of  treatment  is  that  by  means  of  the  adhesive- 
plaster  strapping  advocated  by  Cotrell  and  Gibney.  The  entire 
surface  of  the  knee,  except  a  narrow  space  in  the  popliteal  region, 
is  firmly  strapped  with  overlapping  layers  of  adhesive  plaster, 
extending  from  the  upper  third  of  the  leg  to  the  middle  third  of  the 
thigh;  and  over  this  a  flannel  bandage  is  applied;  or  if  the  leg  is 
swollen,  the  entire  limb  should  be  firmly  bandaged  with  elastic 
stockinette  bandage,  from  the  toes  to  the  upper  third  of  the  thigh 
in  addition  (Fig.  356).  The  adhesive  plaster  serves  as  a  support 
which  permits  a  certain  degree  of  motion,  sufficient  to  stimulate  the 


438      NOX-TUBERCULOrS  AFFECTIONS  OF  KXEE-JOIXT 

circulation,  and  thus  to  hasten  the  restoration  of  the  normal  condi- 
tion. If  gi-eater  compression  is  desired,  the  entire  joint  may  be 
covered  with  the  adhesive  plaster  as  suggested  by  Hoffmann. ^  A 
pad  of  cotton  is  placed  in  the  popliteal  space,  a  close-fitting  stocking 
leg  is  drawn  over  the  knee,  and  about  this  circular  bands  of  plaster 
are  drawn  as  tightly  as  the  comfort  of  the  patient  will  permit.  The 
adhesive  plaster  strapping  is  renewed  from  time  to  time,  as  the 
swelling  diminishes,  and  its  use  is  continued  until  the  symptoms 
have  entirely  disappeared.  Aspiration  is  always  indicated  if  the 
tension  of  the  effused  fluid  causes  discomfort.  If  the  synovitis  per- 
sists and  if  the  capsule  is  thickened  so  that  its  capacity  for  absorp- 
tion is  diminished  it  should  be  incised,  the  contents  removed  by 
flushing  with  hot  salt  solution — afterward  the  interior  may  be 
treated  with  tincture  of  iodin  or  carbolic  acid — the  aim  being  to 
lessen  the  irritability  and  to  stimulate  the  reparative  process. 

•  Cotton^  has  suggested  permanent  internal  drainage  for  cases  of 
this  tA^pe.  An  incision  is  made  on  the  inner  side  of  the  knee,  exposing 
the  fibres  of  the  vastus  internus.  These  are  split,  the  capsule  is 
incised.  The  synovial  membrane  is  opened  and  its  margins  drawn 
through  the  capsule  and  sutiu-ed  to  its  outer  surface.  The  muscle 
is  then  brought  together  and  the  wound  is  closed. 

In  cases  of  chronic  synovitis  the  muscles  are  atrophied  and  the 
ligaments  are  relaxed.  Thus  weakness  and  discomfort  may  persist 
indefinitely  unless  the  normal  tone  is  restored  by  massage  and  by 
regulated  exercises.  In  cases  of  the  more  severe  tjj)e  a  supporting 
brace  is  indicated  for  the  purpose  of  preventing  lateral  movement 
and  limiting  the  anteroposterior  range  to  the  painless  arc 
(Fig.  236). 

Chronic  and  Recurrent  Ssoiovitis. — Chronic  synovitis  is  of  far 
greater  interest  from  the  orthopedic  stand-point  than  the  acute  form 
because  it  is  usually  symptomatic  of  some  general  pathological 
condition  or  change  within  the  joint. 

Bennet^  has  analyzed  750  cases,  the  apparent  causes  of  the 
eft'usion  being  as  follows: 

Local. 

1.  Internal  derangement  of  the  joint 428 

2.  Loose  bodies  in  the  joint 24 

3.  Genu  valgum 4 

General. 

1.  Osteo-arthritis 107 

2.  Rheumatism  and  gout 30 

3.  Syphilis 42 

-4.  Gonorrhea 28 

5.  Malaria 18 

6.  Hemophilia " .      .  3 

1  New  York  Med.  Jour.,  January  27,  1900. 

2  Surg.,  Gynec.  and  Obst.,  July,  1915. 

3  Lancet,  January  7,  1905. 


INTERNAL  DERANGEMENT  OF  THE  KNEE-JOINT       439 

In  56  cases  no  cause  could  be  assigned  and  13  were  instances  of 
''quiet  effusion." 

Incidental  Synovitis. — Strains  of  the  knee-joint  slight  in  degree 
may  be  induced  by  genu  valgum,  by  slipping  patella  and  the  like, 
and  discomfort  about  the  knee  is  not  infrequently  an  accompani- 
ment of  the  weak  foot.  It  may  be  stated  also  that  simple  over- 
weight or  strain  may  induce  discomfort,  creaking  sensations,  and 
slight  effusion  in  the  joint.  In  fact,  overweight  is  the  most  con- 
stant of  all  the  aggravating  causes  of  weakness  in  the  knees  of  the 
character  described.  Reduction  of  weight  by  proper  diet  is  there- 
fore an  important  indication  for  treatment. 

"Quiet  Effusion." — Painless  synovitis  at  the  knee  or  other 
joints  is  sometimes  observed  in  young  females.  It  has  apparently 
some  connection  with  menstrual  irregularities.  Recurrent  effusion 
of  a  similar  character  in  one  or  both  knees  is  occasionally  seen  in 
older  subjects.  Without  appreciable  cause  and  occasionally  at 
fairly  regular  intervals  of  from  fifteen  days  to  a  month  or  more  the 
joint  is  filled  with  fluid,  the  principal  discomfort  being  the  tension. 
The  swelling  persists  for  several  days  and  disappears.  In  the  inter- 
vals the  joint  appears  to  be  normal  except  for  a  certain  laxity  of  the 
ligaments.  Fifty-five  cases  from  literature  have  been  collected  by 
Schlesinger.'^  It  is  classed  by  Kamp^  as  a  trophic  vasomotor 
neurosis.  Thyroid  extract  has  been  employed  in  cases  of  this 
character  with  apparent  benefit.^ 

In  rare  instances  primary  sarcoma  of  the  capsule  may  cause  chronic 
synovitis.  The  principal  diagnostic  points  are  the  local  or  general 
thickening  of  the  capsule  and  the  blood-stained  fluid  obtained  on 
aspiration.  The  course  of  the  disease  is  very  chronic  and  its  malig- 
nancy is  slight.  Thorough  removal  of  the  capsule  with  or  without 
excision  would  seem  to  be  indicated. 

One  case  has  come  under  my  observation  and  8  others  are  reported, 
in  but  1  of  which  was  there  general  dissemination  of  the  disease. 

Other  forms  of  synovitis  or  joint  disease  dependent  upon  general 
constitutional  causes  or  upon  direct  infection  have  been  considered 
in  Chapter  VI. 


INTERNAL  DERANGEMENT  OF  THE  KNEE-JOINT.     (Hey  1782.) 

Internal  derangement  signifies  sudden  interference  with  the 
function  of  the  joint  which  may  be  due  to  (a)  loose  bodies  in  the 
joint;  (6)  displacement  or  fracture  of  a  semilunar  cartilage;  (c) 
other  injury. 


1  Nothnagel:  Spec.  Path.  u.  Jour.  Wien,  1903.  1-27. 

2  Deutsch.    med.    Wchnschr.,    March    21,    1907. 

^  Ribierre:  Bull,  de  la  Soc.  Med.  des  hop.  de  Paris,  1910,  xxvii,  96. 


440      XOX-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 

Loose  Bodies  in  the  Knee-joint.^ — Loose  bodies  in  the  knee-joint 
may  be  composed  of  portions  of  fibrin,  fragments  of  synovial  mem- 
brane, or  bits  of  cartilage  dr  bone,  and  the  like  (osteochondritis  dessi- 
cans).  In  certain  forms  of  synovial  tuberculosis,  arthritis  deformans 
or  similar  chronic  affections,  loose  bodies  maybe  present  in  large  num- 
bers (osteochondi'omatosis) .  From  the  therapeutic  stand-point,  how- 
ever, the  important  cases  are  those  in  which  the  joint  is  otherwise 
normal.  In  this  class  the  foreign  body  is  sometimes  detected  by  the 
patient  as  a  smooth,  movable  object  on  one  or  the  other  side  of  the 
patella;  but  in  many  instances  the  first  sign  of  its  presence  is  inter- 
ference with  the  function  of  the  joint.  After  a  sudden  movement  or 
when  the  knee  has  been  flexed,  as  in  the  kneeling  position,  or  without 
appreciable  cause,  severe  pain  in  the  knee  is  felt  and  the  joint  may  be 
fixed  in  the  position  of  flexion.  By  massage,  manipulation,  or  spon- 
taneously the  foreign  body  is  dislodged  from  between  the  surfaces  of 
the  bone  and  movement  becomes  free  and  painless,  but  discomfort 
remains  for  a  time  and  in  most  instances  synovial  eft'usion  follows. 
These  s^inptoms  recm-  at  intervals,  and  the  disappearance  of  the  mov- 
able body  from  its  accustomed  place  at  such  times  may  demonstrate 
its  relation  to  the  disability. 

Displacement  of  a  Semilunar  Cartilage. — By  far  the  most  com- 
mon cause  of  sudden  interference  with  motion  at  the  knee-joint  is 
displacement  of  the  internal  semilunar  cartilage.  This  is  caused  by  a 
wrench  or  sudden  inward  rotation  of  the  femur  on  a  fixed  tibia  in  the 
attitude  of  flexion. 

There  is  pain,  often  a  sensation  of  something  slipping,  followed 
by  inability  to  extend  the  limb. 

The  accident  is  especially  common  among  miners  who  often  work 
with  the  knees  flexed,  and  those  who  engage  in  violent  exercises, 
as  football. 

An  eftective  method  of  reduction  is  that  of  Whitelocke : 

Place  the  patient  flat  on  his  back.  Standing  on  the  outer  side 
of  the  affected  limb,  flex  the  leg  on  the  thigh  and  the  thigh  on  the 
trunk  as  much  as  possible;  at  the  same  time  adduct  the  limb  until 
the  flexed  knee  comes  to  lie  across  the  middle  line  of  the  body  at  the 
navel.  With  the  limb  in  this  position  all  the  ligaments  and  tendons 
are  slackened.  Take  hold  of  the  ankle  with  one  hand  and  grasp  the 
knee  with  the  other  to  steady  it.  ^Yith  the  hand  on  the  ankle, 
abduct  the  tibia  from  the  femoral  condyle,  so  as  to  open  the  space  as 
widely  as  possible,  then  with  the  leg  used  as  the  long  arm  of  a  lever 
work  it  to  and  fro  with  slight  movements  of  rotation  until  the  car- 
tilage is  felt  to  slip  back,  the  patient  experiences  relief,  and  the  knee 
becomes  capable  of  full  extension.     When  the  external  cartilage 

1  According  to  Immelmann  (Ztschr.  f.  artz.  Fortbildung,  1904,  Xo.  5),  in  30  per 
cent,  of  normal  indi^"iduals  a  sesamoid  bone  may  be  found  beneath  the  external  head 
of  the  gastrocnemius  muscle  that  might  on  an  a;-ray  examination  be  mistaken  for 
loose  body  within  the  joint. 


INTERNAL  DERANGEMENT  OF  THE  KNEE-JOINT      441 


is  at  fault,  the  abduction  of  the  tibia  must  be  from  the  external 
femoral  condyle  and  the  rotation  in  the  opposite  direction. 

In  some  instances  an  anesthetic  may  be  required.  Displacement 
of  the  semilunar  cartilage  is  usually  followed  by  effusion,  sensitive- 
ness to  pressure  over  the  internal  border  of  the  tibia — and  by  the 
ordinary  symptoms  of  the  sprain.  The  accident  having  once 
occurred,  is  likely  to  recur;  the  patient  recognizing  the  movements 
that  are  likely  to  cause  the  displacement,  learns  also  the  proper 
manipulation  for  its  replacement. 


Fig.  342 
Figs.  342  and  343. 


Fig.  343 
-The  Griffiths  brace.      (Jones.) 


Displacement  of  the  external  cartilage  is  comparatively  uncom- 
mon, because  it  is  less  exposed  to  strain  by  the  movements  of  the 
joint  and  less  intimately  connected  with  the  capsule.  The  symp- 
toms are  like  those  described,  the  discomfort  being  referred  to  the 
outer  aspect  of  the  joint.  It  is  one  of  the  causes  of  the  snapping 
knee. 

In  other  instances  somewhat  similar  symptoms  may  follow  injury 
at  the  knee ;  pinching  of  the  synovial  membrane,  bruising  or  fracture 
of  the  cartilage,  or  a  strain  of  one  of  the  ligaments  within  the  joint, 
being  assigned  as  causes.  In  cases  of  this  character,  in  which 
symptoms  recur  from  time  to  time,  the  joint  becomes  weak  and 
insecure,  partly  because  of  the  repeated  synovial  effusion  and  partly 
because  of  the  muscular  relaxation. 

Treatment. — If  the  displacement  is  primary,  after  reduction  the 
limb  should  be  fixed  in  a  plaster  bandage  for  two  weeks  or  more  to 
allow  for  reattachment  at  the  point  of  rupture.     Afterward  the  joint 


442      NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 

may  be  protected  by  the  adhesive  plaster  strapping,  and  when  the 
effusion  has  been  absorbed  massage  and  exercises  for  strengthening 
the  muscles  should  be  employed.  The  patient  should  avoid  pre- 
disposing attitudes  and  should  cultivate  "straight  walking"  in 
order  to  remove  the  strain  from  the  inner  aspect  of  the  joint. 

In  the  more  chronic  cases  in  which  the  ligaments  are  lax,  a  brace 
which  will  permit  anteroposterior  motion  but  prevent  lateral 
mobility,  may  be  required.  The  Campbell  brace  (Fig.  205),  used 
by  Shaffer,  is  a  light  and  effective  support  that  interferes  little,  if  at 
all,  with  the  use  of  the  limb.  Jones,  w^hose  experience  has  been 
large  uses  the  Griffiths  brace  to  limit  lateral  motion  (Fig.  342),  and 
various  forms  of  knee  caps  and  bandages  are  applied  by  the  patients. 


Fig.  344. — Complete  exposure  of  the  joint  by  the  median  incision  of  Jones,  show- 
ing division  of  tendons  and  fat  pad  with  ligamentum  mucosum  intact  and  attached 
to  intercondylar  notch.  Floor  and  lower  edge  of  quadriceps  pouch  is  seen  above. 
(Brackett.) 

If  the  diagnosis  of  displaced  or  fractured  cartilage  can  be  verified, 
and  if  it  is  the  cause  of  serious  disability,  it  should  be  removed. 
And  the  same  may  be  said  of  isolated  foreign  bodies  which  are  known 
to  be  the  cause  of  the  symptoms. 

The  operation^  should  be  performed  under  the  Esmarch  bandage 
with  the  leg  flexed  upon  the  thigh  to  a  right  angle,  and  dependant. 
A  perpendicular  incision  about  three  inches  in  length  is  made  mid- 


1  Jones:  Ann.  Surg.,  December,  1909.     Whitman:    Med.    Rec,   July  22,    1916. 


OSTEOCHONDRITIS  DE  SSI  CANS  443 

way  between  the  internal  lateral  ligament  and  the  patella.  When 
the  capsule  is  opened  the  detached  cartilage,  drawn  away  from  the 
tibia  by  the  tension  on  the  capsule,  comes  into  view.  It  may  be 
normal  in  appearance  or  yellowish  in  color  and  distorted. 

It  is  divided  into  two  parts  by  continuing  the  incision  downward. 
The  anterior  half  may  be  detached  by  the  forceps. 

The  posterior  part  is  attached  to  the  capsule  from  which  it  must 
be  dissected  in  order  to  remove  it  easily. 

The  synovial  and  capsular  incisions  are  then  united  with  fine 
catgut,  the  wound  is  closed,  and  a  plaster  bandage  is  applied  in 
slight  flexion.  At  the  end  of  a  week  or  more  the  patient  may  walk 
about.  At  the  end  of  a  month  the  adhesive  plaster  strapping  may 
replace  the  bandage  or  preferably  in  cases  of  long  standing  the 
Campbell  brace  may  be  applied.  Perfect  functional  recovery  is  the 
rule. 

OSTEOCHONDRITIS  DESSICANS. 

This  name  was  first  suggested  by  Konig^  for  a  disability,  most 
common  at  the  knee,  characterized  by  loose  bodies  in  the  joint. 

Injury  is  considered  the  most  prominent  factor  in  the  etiology, 
in  breaking  ofi^  fragments  of  cartilage,  or  causing  necrosis  either 
directly  or  indirectly  by  interference  with  the  circulation. 

As  exposed  at  operation  the  fragments  or  bodies  may  be  loose  or 
adherent,  often  single,  in  which  case  a  depressed  area  indicating  a 
point  of  possible  detachment  is  often  apparent  usually  about  the 
outer  margin  of  the  internal  condyle.  Less  often  there  are  two  or 
more  bodies.  They  are  small,  thin,  smooth  and  cartilaginous  in 
structure,  most  often  found  in  the  anterior  chamber  of  the  joint. 

Both  the  loose  body  and  the  irregular  area  on  the  anterior  border 
of  the  internal  condyle  are  often  apparent  in  the  ic-ray  picture 
confirming  the  diagnosis. 

The  patients  are  usually  males  whose  occupation  is  laborious. 

The  symptoms  are  weakness  and  discomfort,  "catching"  or  lock- 
ing of  the  joint,  with  the  secondary  symptoms  and  changes  corre- 
sponding to  the  degree  of  interference  with  function. 

When  the  diagnosis  is  clear  removal  is  indicated.  This  may  be 
best  accomplished  by  the  median  division  of  the  patella  as  suggested 
by  Jones.2  A  long  incision  is  made  over  the  patella,  extending  from 
the  base  of  the  quadriceps  tendon  above  to  the  insertion  of  the  patel- 
lar tendon  below. 

The  patella  is  cut  with  a  saw  in  the  centre  and  the  other  tissues 
are  cut  in  the  same  line  and  retracted.  In  an  attitude  of  right 
angular  flexion  the  joint  is  completely  exposed.  After  removal  of 
the  foreign  body  the  synovial  membrane  is  carefully  closed,  and  the 

1  Deutsch.  Ztschr.  f.  Chir.,  1890,  xxvii. 

2  British  Med.  Jour.,  August,  1916. 


44J:      NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 

tendon  above  and  below  the  patella  sutured  accurately  apposing 
the  fragments. 

Ordinarily  the  joint  is  found  in  a  healthy  condition  and  complete 
restoration  of  function  is  the  rule.^ 

Loose  bodies  in  the  ankle,  elbow  and  other  joints  are  of  similar 
origin. 

OSTEOCHONDROMATOSIS. 

In  some  instances  loose  bodies  are  multiple,  produced  apparently 
by  cartilaginous  transformation  of  projecting  fringes  of  synovial 
membrane.  Removal  is  indicated,  but  the  prognosis  is  naturally 
less  favorable  than  in  cases  of  the  preceding  class.^ 

HYPERPLASIA. 

Hyperplasia  of  Fatty  Tissue  within  the  Joint. — ^The  largest  of  the 
pads  of  fibrofatty  tissue  within  the  knee-joint  is  of  a  somewhat 
triangular  form,  its  base  lying  in  the  interval  between  the  femur  and 
the  tibia,  its  apex  projecting  upward,  held  between  the  femoral 
condyles  by  the  ligamentum  patellae  and  the  ligamentum  mucosum. 
This  may  become  enlarged  and  sensitive  to  motion  and  pressure. 
The  patient  suffers  from  discomfort  particularly  on  changing  from 
a  position  of  rest  to  activity  and  from  creaking  sensations  or  even 
interference  with  motion.  At  times  synovitis  may  be  present  and 
in  many  instances  a  resistant  swelling  is  apparent  on  either  side  of 
the  patella  and  its  ligament. 

Treatment. — If  the  SAinptoms  are  not  relieved  by  rest,  strapping 
or  other  conservative  treatment,  the  removal  of  the  hypertrophied 
tissue  is  indicated.  Sensitive  tumors  of  a  similar  nature  may  appear 
in  other  parts  of  the  joint  and  folds  or  masses  of  hj^Dertrophied 
synovial  membrane,  the  effect  usually  of  repeated  inflammation 
may  induce  similar  sjonptoms.  In  such  cases  exploration  of  the  joint, 
for  the  purpose  of  ascertaining  the  cause  of  the  s;\^nptoms  or  for 
removal  of  the  obstructing  parts,  is  indicated. 

BURSITIS. 

Prepatellar  Bursitis. — Synonym. — Housemaid's  knee. 

Enlargement  of  the  bm*sa  lying  over  the  patella  and  its  ligament 
is  common  among  those  who  have  to  kneel  much  of  the  time ;  hence 
the  popular  name.  Occasionally  cases  of  acute  bursitis,  in  which 
there  is  considerable  effusion  into  the  sac,  are  seen,  and  these  are 
sometimes  mistaken  for  synovitis  of  the  knee. 

Treatment. — In  acute  cases  strapping  the  front  of  the  knee  with 
strips  of  adhesive  plaster  which  will  limit  motion  and  provide  com- 

1  Brackett:  Am.  Jour.  Orthop.  Surg.,  Februarj-,  1917. 

2  Henderson:  Am.  Orth.  Assn.,  May,  1917. 


INJURY  OF  THE  TIBIAL  TUBERCLE  445 

pression  is  an  effective  treatment.  If  the  effusion  is  considerable 
it  may  be  relieved  by  aspiration  or  incision.  In  chronic  cases  cure 
can  be  attained  only  by  the  removal  of  the  thickened  sac. 

Pretibial  Bursitis. — Beneath  the  ligamentum  patellae,  occupying 
the  space  between  the  tendon  and  the  periosteum  of  the  tibia,  is  the 
deep  pretibial  bursa.  It  is,  according  to  the  investigations  of 
Lovett,^  as  wide  or  somewhat  wider  than  the  tendon;  its  upper 
border  is  on  a  level  with  the  joint,  its  lower  border  reaches  to  the 
tubercle  of  the  tibia,  and,  being  slightly  longer  on  the  outer  than  on 
the  inner  jDorder,  it  is  somewhat  triangular  in  shape.  It  does  not 
communicate  with  the  knee-joint. 

Enlargement  of  this  bursa  is,  as  a  rule,  the  result  of  injury,  but, 
as  bursitis  elsewhere,  it  may  be  a  complication  of  infectious  diseases, 
rheumatism  and  the  like. 

Symptoms. — ^The  symptoms  are  stiffness  at  the  knee  and  pain  on 
sudden  movement,  especially  when  strain  is  exerted  on  the  tendon 
by  complete  flexion  or  extension  of  the  leg  as  in  active  use.  The 
tubercle  of  the  tibia  seems  enlarged  and  is  sensitive  to  pressure,  and 
a  swelling  on  either  side  of  the  ligament  is  usually  evident. 

Treatment. — The  affection,  if  at  all  acute,  may  be  treated  by  reliev- 
ing the  strain  and  pressure  on  the  tendon,  by  fixation  of  the  limb 
for  a  time  in  a  plaster  bandage  or  other  form  of  splint.  Later  the 
adhesive-plaster  strapping  will  provide  sufficient  fixation  and  pres- 
sure. The  absorption  of  the  fluid  may  be  hastened  by  the  applica- 
tion of  the  cautery.  If  the  swelling  is  persistent,  the  fluid  may  be 
removed  by  aspiration  or  incision  or  removal  of  the  sac. 

ENLARGEMENT  OF  THE  SUPERFICIAL  PRETIBIAL  BURSA. 

A  small  bursa,  lying  upon  the  insertion  of  the  ligamentum  patellae, 
may  become  enlarged,  causing  an  apparent  hypertrophy  of  the 
tubercle  of  the  tibia  which  is  sensitive  to  pressure.  It  may  be 
treated  by  strapping  with  adhesive  plaster,  and  the  prominent 
tubercle  should  be  protected  by  some  form  of  bunion  plaster. 

INJURY  OF  TIBIAL  TUBERCLE.      ("SCHLATTER'S  DISEASE. 'O^ 

In  childhood  and  adolescence  the  tibial  tubercle,  a  tongue-like 
prolongation  of  the  epiphysis  of  the  tibia,  is  not  united  to  the 
shaft  and  may  be  partly  separated  from  its  attachment  by  sudden 
strain  or  contraction  of  the  quadriceps  extensor  muscle.  The 
symptoms  are  local  pain,  sensitiveness  and  apparent  enlargement 
of  the  tubercle.  The  diagnosis  may  be  confirmed  by  a;-ray  exami- 
nation. In  other  instances  one  or  both  tubercles  may  be  enlarged 
or  sensitive  without  history  of  direct  injury. 

1  Boston  City  Hospital  Reports,  1897,  8th  series. 

2  Beitr.  z.  klin.  Chir.,  xxxviii,  3. 


446      NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 

Treatment. — The  limb  should  be  fixed  in  the  extended  position 
by  a  plaster  bandage  until  union  is  firm.^  If  actual  displacement  is 
present  open  operation  for  reduction  and  reattachment  is  indicated. 

BURS^  AND  CYSTS  IN  THE  POPLITEAL  REGION. 

Bursitis  of  the  sac  lying  between  the  inner  head  of  the  gastroc- 
nemius and  the  semimembranosus  muscles  may  cause  a  fluctuating 
swelling  on  the  inner  side  of  the  popliteal  region.  It  may  be  treated 
by  compression,  by  incision,  or  by  complete  removal  as  may  seem 
advisable.^  Cysts  in  the  popliteal  region  often  communicate  with 
the  knee-joint  and  are  complications  of  rheumatic  or  tuberculous 
disease.  In  such  cases  they  are  of  interest  principally  from  the 
diagnostic  stand-point. 

ACQUIRED  GENU  RECURVATUM. 

Synonym. — Back  knee. 

Genu  recurvatum,  as  the  name  implies,  is  a  deformity  in  which 
the  knee  is  habitually  overextended. 

Etiology. — Acquired  genu  recurvatum  may  be  a  simple  local 
deformity,  or  it  may  be  secondary  to  weakness  or  distortion  of  other 
parts.  Local  or  primary  genu  recurvatum  may  be  an  effect  of 
rhachitis,  or  of  disease  or  injury  of  the  femur  or  tibia.  In  this  form 
the  femur  may  be  curved  sharply  forward  above  the  joint,  or  the 
upper  extremity  of  the  tibia  may  be  bent  backward  at  the  epiphyseal 
junction,  and  flexion  may  be  limited  by  the  obliquity  of  the  articu- 
lating surfaces. 

More  often  the  deformity  is  secondary'.  It  may  be,  for  example, 
an  effect  of  equinus,  either  congenital  or  acquired,  in  which  the  knee 
is  strained  by  the  eft'ort  of  the  patient  to  place  the  heel  upon  the 
ground.  It  may  be  caused  by  the  use  of  a  brace  in  the  treatment  of 
hip  disease,  if  the  knee-joint  is  not  properly  supported,  and  it  is 
often  seen  also  as  a  result  of  disease  at  this  joint,  for  which  no 
apparatus  has  been  employed.  It  even  appears  in  some  instances 
on  the  sound  side,  apparently  as  a  form  of  compensation  for  the 
shorter  limb  (Fig.  249).  It  is  one  of  the  comparatively  infrequent 
complications  of  disease  at  the  knee-joint,  for  which  the  leg  has  been 
supported  by  the  brace  in  an  extended  or  overextended  position, 
or  in  which  the  growth  at  the  epiphyseal  cartilage  of  the  femur  or 
tibia  has  been  irregular.  In  rare  instances  it  is  the  direct  result  of 
traumatism,  as  when  the  limb  has  been  suddenly  forced  into  an 
overextended  position,  and  the  posterior  ligaments,  and  possibly 
the  crucial  ligaments,  also,  have  been  ruptured  or  weakened.  It  is 
most  often,  however,  an  accompaniment  of  paralysis  of  the  posterior 

1  Osgood:  Boston  Med.  and  Surg.  Jour.,  January  29,  1903. 
=  Riedal:   Deutsch.  Ztschr.  f.  Chir.,  1915,  cxxxii,  144. 


CONGENITAL  GENU  RECURVATUM  447 

thigh  muscles  or  of  the  gastrocnemius  muscle,  or  both.  A  slight 
degree  of  overextension  at  the  knees  is  not  uncommon  in  children 
who  have  the  so-called  loose  joints,  and  it  is  often  observed  in 
ataxic  subjects. 

In  many  cases  genu  recurvatum  is  combined  with  a  varying 
degree  of  knock-knee,  and  there  is  often  an  abnormal  mobility  at 
the  joint  that  allows  a  certain  amount  of  posterior  displacement 
of  the  tibia.  In  extreme  cases  of  this  class  there  may  be  well- 
marked  subluxation. 

Symptoms. — The  symptoms,  aside  from  the  deformity,  are 
weakness  and  insecurity  caused  by  the  hyperextension  when  weight 
is  borne.  If  the  deformity  is  extreme,  the  strain  upon  the  weakened 
parts  usually  causes  discomfort.  Flexion  is  rendered  difficult  because 
of  the  abnormal  relation  of  the  joint  surfaces  and  by  the  accommo- 
dative changes  in  the  ligaments  and  muscles,  so  that  in  extreme 
cases  the  patient  swings  the  leg  along  in  the  extended  or  overextended 
position. 

Treatment. — If  the  recurvation  is  caused  by  deformity  of  the 
bones,  the  normal  relations  may  be  restored  by  osteotomy  of  the 
tibia  or  femur,  as  may  be  indicated.  Deformity  secondary  to  dis- 
tortions elsewhere  may  be  treated  by  remedying  the  primary  cause. 

Traumatic  genu  recurvatum  may  be  treated  by  fixation  in  the 
flexed  position  until  the  repair  is  complete,  afterward  by  massage 
and  support  if  necessary.  The  ordinary  form  of  overextended 
knee,  combined  with  lateral  mobility,  must  be  supported  by  a  brace 
which  checks  extension  slightly  within  the  normal  limit.  Whenever 
possible  massage  and  exercises  should  be  employed. 

CONGENITAL  GENU  RECURVATUM. 

Synonym. — Anterior  displacement  of  the  tibia. 

The  most  common  of  the  congenital  deformities  at  the  knee  is 
the  so-called  genu  recurvatum,  in  which  the  knee  is  bent  somewhat 
backward;  or,  in  other  words,  the  leg  is  hyperextended  on  the 
thigh.  The  condition  is  often  spoken  of  as  an  anterior  dislocation, 
but  this  term  should  be  limited  to  the  more  extreme  cases  (Fig.  346) . 
Ordinarily  the  range  of  extension  is  merely  exaggerated,  while  flex- 
ion is  limited  or  checked,  by  adaptive  shortening  of  the  quadriceps 
extensor  muscle.  In  some  cases  there  may  be  changes  in  the  direc- 
tion of  the  articulating  surfaces  in  adaptation  to  the  deformity  of 
the  femur  and  tibia. ^ 

The  appearance  in  well-marked  genu  recurvatum  is  very  peculiar; 

it  is  as  if  the  patient's  leg  were  reversed,  for  the  popliteal  depression 

has  become  a  prominence  and  the  range  of  overextension  seems  to 

.  represent  normal  flexion.     In  such  cases  the  leg  may  be  brought 

1  Delanglade:  Rev.  d'Orthop.,  May,  1903. 


448      NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 

to  the  straight  hne,  but  greater  flexion  is  resisted  by  the  retracted 
tissues,  and  when  the  pressure  of  the  hand  is  removed  the  leg  is 


Fig.  345. — ^Congenital  geuu  recur vatum. 


drawn  back  to  the  deformed  position  by  the  contraction  of  the 
quadriceps  extensor  muscle. 


Fig.    346. — X-ray  picture  of    Case  345,  showing  the  aDterior    displacement  of  the 
tibiae  on  the  femora. 


Accompanying  Deformities   and  Malformations. — Genu    recur- 
vatum  is  not  infrequently  accompanied  by  varus  or  valgus  deform- 


CONGENITAL  GENU  RECURVATUM 


449 


ity  at  the  knee,  more  often  by  the  latter,  and  by  laxity  of  the  liga- 
ments. In  many  instances  the  patella  is  absent  or  is  rudimentary, 
and  not  infrequently  the  deformity  is  accomplished  by  malforma- 
tions or  defective  development  of  other  parts. 

Rechman^  has  collected  188  cases.  Of  those  analyzed,  19  were 
in  males,  29  in  females;  18  were  unilateral,  35  bilateral. 

Dislocation  of  the  hip  was  present  in  27,  and  abnormalities  of  the 
feet  in  29  cases.  In  at  least  half  the  cases  the  patella  is  absent  or 
rudimentary. 


Fig.  347. — The  mother  of  Case  375  who  had  the  same  cODgenital  deformity. 
Displacement  and  laxity  persist  on  the  right.  The  patellae  were  probably  injured 
during  treatment. 

Etiology. — The  deformity  in  cases  of  simple  recurvatum  may  be 
explained  by  an  abnormal  and  fixed  position  in  utero,  and  in  certain 
cases  seen  soon  after  birth  the  mechanism  is  clearly  shown  by  the  hab- 
itual attitude.  The  thighs  are  sharply  flexed  on  the  body;  the  dorsal 
surfaces  of  the  hyperextended  knees  are  in  relation  to  the  abdomen, 
while  the  feet  may  be  brought  into  contact  with  the  face  or  trunk, 
according  to  the  degree  of  deformity.  The  retarded  development 
of  the  quadriceps  extensor  muscle  explains  the  rudimentary  patella 
which  is  often  an  accompaniment  of  the  deformity. 

Treatment. — The  treatment  of  the  hyperextended  knee  is  very 
simple.  It  consists  in  massage  of  the  atrophied  and  contracted 
muscles,  combined  with  more  or  less  forcible  manipulation  in  the 
direction  of  flexion.  If,  as  is  often  the  case,  the  leg  seems  to  be 
drawn  forward  by  spasmodic  muscular  action,  the  methodical  mas- 
sage should  be  combined  with  the  use  of  a  simple  posterior  splint. 

1  Arch.  f.  orthop.  Mech.  und  unfall.  Chir.,  1914,  Band  xiii,  Heft  3. 
29 


450      NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 

In  the  more  extreme  cases  manual  force  may  be  applied  under 
anesthesia,  and  the  deformity  may  be  overcome  at  one  or  several 
sittings,  according  to  the  resistance  of  the  contracted  parts.  The 
limb  is  then  fixed  in  a  flexed  position  until  the  tendency  to  recur- 
rence has  been  overcome.  When  the  child  begins  to  walk  a  light 
lateral  brace  may  be  necessary  to  ensure  perfect  functional  use  of 
the  joint,  as  in  many  instances  laxity  of  ligaments  and  muscular 
weakness  may  persist  for  a  long  time. 

RUDIMENTARY  OR  ABSENT  PATELLA. 

As  has  been  stated,  a  rudimentary  patella  is  a  frequent  compli- 
cation of  genu  recurvatum  or  of  any  congenital  defect  or  deformity 
of  the  knee  or  limb  that  involves  imperfect  development  of  the 
quadriceps  extensor  muscle.  In  many  cases  of  this  type  it  is  impos- 
sible to  distinguish  the  patella  during  the  early  months  of  infancy, 
but  later  a  minute  patella  appears  that  slowly  increases  to  an 
approximately  normal  size. 

Absence  of  patella  under  the  same  conditions  is  less  frequent, 
although  Potel  collected  100  cases  from  literature. 

Treatment. — The  treatment  of  rudimentary  patella  is  included 
in  the  massage  and  stimulation  of  the  atrophied  or  rudimentary 
muscle  with  which  it  is  usually  associated,  and  the  support  that  the 
weak  or  deformed  knee  may  require. 

CONGENITAL  AND  ACQUIRED  DISPLACEMENT  OF  THE 
PATELLA. 

The  patella  may  be  displaced  upward  as  a  result  of  extreme  genu 
recurvatum,  and  in  rare  instances  it  may  be  displaced  inward  or 
downward,  but  far  more  often  the  displacement  is  outward.  Fifty 
cases  of  this  form  are  recorded,  in  most  of  which  it  was  a  compli- 
cation of  congenital  genu  valgum. 

Acquired  complete  displacement  in  which  the  patella  lies  on  the 
outer  aspect  of  the  external  condyle  is  most  often  an  accompaniment 
of  extreme  genu  valgum.  The  first  step  in  treatment  must  be  to 
remedy  the  distortion  of  the  limb,  but  if  the  deformity  is  of  long 
duration  the  tissues  on  the  anterior  aspect  will  have  become  so 
shortened  that  flexion  will  be  much  limited  so  that  operative  elonga- 
tion of  the  contracted  tissues  may  be  required. 

SLIPPING  PATELLA. 

This  term  is  applied  to  an  abnormal  laxity  of  the  supporting 
tissues  that  allows  occasional  displacement  of  the  patella  upon  or 
to  the  outer  side  of  the  external  condyle. 

Etiology. — This  disability  is  more  common  among  females  than 
males,  and  is  more  often  unilateral  than  bilateral.     The  abnor- 


SLIPPING  PATELLA 


451 


mal  mobility  may  be  an  inherited  peculiarity;  it  may  be  due  to 
weakness  of  the  quadriceps  extensor  muscle,  or  to  imperfect  develop- 
ment of  the  patella  or  of  the  external  condyle;  or  the  original  dis- 
placement may  have  been  due  to  injury.  In  many  instances, 
however,  the  predisposing  cause  is  genu  valgum,  as  a  consequence  of 
which  the  patella  is  carried  toward  the  external  condyle.  Slight 
occasional  displacement  sufficient  to  cause  discomfort  is  a  not 
uncommon  accompaniment  of  weak  feet,  an  indication,  as  a  rule, 
of  muscular  weakness  or  relaxation. 

Weimuth^  has  collected  66  cases.  Of  these  32  were  of  congenital, 
14  of  traumatic  (rupture  of  internal  ligaments),  and  20  of  patho- 
logical origin  (knock-knee) . 


Fig.  348. — Slipping  patella  of  the  left  side. 


Symptoms. — If  the  slipping  of  the  patella  is  a  frequent  occur- 
rence it  causes  comparatively  little  pain,  but  when  the  parts  are 
less  relaxed  the  displacement  is  likely  to  be  followed  by  a  certain 
amount  of  effusion  into  the  joint  and  by  the  symptoms  of  a  sprain. 
It  is  usually  the  result  of  a  misstep  or  sudden  movement  when  the 
thigh  muscle  is  relaxed  or  of  extreme  flexion  of  the  leg.  As  a  rule 
there  is  a  sense  of  insecurity  and  weakness  at  the  knee  in  those  who 
are  subject  to  the  accident. 

Treatment. — ^The  treatment  varies  according  to  the  condition 
of  the  parts  about  the  joint.  If  the  displacement  is  the  direct 
result  of  violence  the  leg  should  be  fixed  for  a  time  in  a  plaster 

1  Deutsch.  Ztschr.  f.  Chir.,  Ixi;  Bade:  Ztschr.  f.  orthop.  Chir.,  1903,  xi,  451. 


452      NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOiNT 

bandage,  which  may  be  replaced  by  the  adhesive-plaster  strapping 
or  a  knee-cap.  The  improvement  of  the  muscular  tone  by  exercises 
is  always  an  important  part  of  treatment  whether  or  not  support 
is  employed.  In  cases  in  which  the  slipping  has  become  habitual 
and  particularly  when  the  ligaments  of  the  joint  are  much  relaxed, 
a  light  brace  should  be  employed  to  prevent  lateral  motion  and  to 
limit  the  range  of  flexion  at  the  joint,  if  this  predisposes  to  the  dis- 
placement. 


Fig.  349. — Krogius'  operation  for  displaced  patella. 


Operative  Treatment. — If  the  position  of  the  patella  that  predis- 
poses to  the  finther  displacement  is  a  consequence  of  genu  valgum 
the  rectification  of  the  deformity  will,  as  a  rule,  remedy  the  secondary 
disability.  If  the  displacement  appears  to  be  caused  by  laxity  of 
the  capsular  ligament,  as  well  as  by  the  abnormal  position  of  the 
patella,  an  operation  for  the  purpose  of  limiting  the  mobility  and 
restoring  the  proper  relation  of  parts  may  be  conducted  in  the  fol- 
lowing manner :  A  long,  curved  incision  is  made  about  the  inner  side 
of  the  knee,  the  lower  extremity  of  which  crosses  the  ligamentum 
patellse.  The  skin-flap  having  been  reflected,  the  contracted  cap- 
sule may  be  divided  on  the  outer  side  without  disturbing  the  synovial 
membrane.  The  patella  is  then  forced  inward  and  the  redundant 
tissue  on  the  inner  side  is  folded  and  sutured,  or  a  section  of  the 
capsule  may  be  removed,  sufficient  in  size  to  hold  the  patella  in  its 
proper  position.  As  an  additional  safeguard  a  section  of  the  semi- 
membranosus tendon  may  be  transplanted  to  the  inner  border  of 
the  ligamentum  patellae  or  the  tendon  of  the  gracilis  may  be  used 
for  the  same  pm-pose.^  (Whitlock.)  A  more  radical  procedure  is 
that  of  Ki'ogius. 

1  Ztschr.  f.  Chir.,  1904,  No.  24. 


ELONGATION  OF  THE  LIGAMENTUM  PATELLAE        453 

The  contracted  capsule  is  first  thoroughly  divided  on  the  outer 
side  as  in  the  previous  operation  and  the  patella  is  forced  over  to 
its  normal  position.  From  the  redundant  capsule  on  the  inner  side  a 
strip  one  inch  or  more  in  width  from  the  tibia  to  and  including  the 
muscle  is  separated  from  the  synovial  sac  and  the  musculo-apo- 
neurotic  section  is  carried  over  the  patella  to  fill  the  opening 
in  the  outer  part  of  the  capsule.  The  various  incisions  are  then 
closed  with  sutures.  In  extreme  cases  the  tubercle  of  the  tibia,  with 
the  attached  tendon,  may  be  removed  and  reimplanted  on  the  inner 
aspect  of  the  tibia,  or  the  ligament  may  be  split  into  equal  parts.  The 
outer  half  is  then  detached,  passed  beneath  the  inner  and  attached 
to  the  insertion  of  the  sartorius  muscle  and  the  periosteum  on  the 
inner  side  of  the  tibia.  (WoM  and  Walsham.^  After  operation 
the  limb  should  be  held  in  the  extended  position  for  a  time,  and  it 
should  afterward  be  supported  by  a  brace  or  knee-cap  for  several 
months.  Subsequently  massage  and  exercise  for  restoring  the  tone 
of  the  w^eakened  muscles  should  be  employed. 

Albee^  would  prevent  displacement  by  elevating  the  external 
condyle.  This  is  split  on  its  outer  aspect,  pried  upward  with  a 
chisel,  and  the  interval  filled  with  a  graft  taken  from  the  tibia. 

ELONGATION  OF  THE  LIGAMENTUM  PATELLA. 

In  certain  cases  the  ligamentum  patellae  may  be  abnormally  long, 
so  that  the  patella  lies  habitually  above  its  proper  position.  This 
elongation  may  be  one  of  the  evidences  of  general  relaxation  of 
the  ligaments  of  the  knee,  and  thus  a  predisposing  cause  of  the 
slipping  patella  or  of  the  abnormal  mobility  at  the  knee-joint. 

Etiology. — The  elongation  of  the  tendon  may  be  a  congenital 
peculiarity  or  it  may  be  acquired.  It  is  most  often  observed  as  an 
effect  of  hemiplegia  or  paraplegia. 

Symptoms. — ^The  symptoms  of  elongation  of  the  ligamentum 
patellae,  as  distinct  from  those  of  the  general  laxity  of  the  ligaments 
that  is  often  present,  are  weakness  and  disability,  usuaUy  noticeable 
on  walking  up  or  down  stairs,  or  after  overexertion.  Shaffer,  who 
first  called  attention  to  the  disability  from  this  cause,  thinks  that 
it  may  be  a  predisposing  cause  of  displacement  of  the  semilunar 
cartilages.^ 

Treatment. — In  this,  as  in  other  forms  of  insecurity  or  of  ab- 
normal mobility  at  the  knee,  a  brace  that  allows  only  antero- 
posterior motion  will,  as  a  rule,  relieve  the  symptoms.  If  the 
ligament  is  of  such  a  length  as  to  require  it,  it  may  be  shortened, 
or  the  tubercle  of  the  tibia  may  be  removed  and  implanted  at 
a  lower  point,  as  suggested  by  Walsham."* 

1  Wolff,  Walfham  and  Goldtwait:     Am.  Jour.  Orthop.  Surg.,  i,  298. 

2  Med.  Rec,  August  4,  1915.  3  Tr.   Am.   Orthop.   Assn.,   xi, 
^  Med.  Weekly,  February  17,   1893. 


454      XOX-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT 


OTHER  CONGENITAL  DEFORMITIES  AT  THE  KNEE. 

Congenital  displacements  are  uncommon.  As  a  rule  they  are 
incomplete  and  are  caused  by  laxity  of  the  ligaments  and  by  defec- 
tive formation  of  the  bones  or  other  parts.^ 

Snapping  Knee. — A  very  slight  form  of  partial  recm'rent  dis- 
placement is  the  snapping  or  clicking  knee  not  uncommon  in  early 
infancy,  in  which  the  tibia  on  sudden  extension  of  the  limb  springs 
forward  or  rotates  outward  on  the  femur  with  an  audible  snap- 
ping sound.  This  movement  appears  to  be  the  result  of  volun- 
tary muscular  contraction  combined  with  laxity  of  ligaments  and 
very  possibly  with  irregular  movements  of  one  or  other  of  the  semi- 
lunar cartilages.  In  some  instances  the  subluxation  appears  to 
cause  pain  or  discomfort.  The  ability  to  displace  the  tibia  on  the 
femur  by  muscular  action  is  sometimes  noted  in  older  subjects.  In 
such  cases  it  may  be  the  result  of  injiu^y  such  as  rupture  of  ligaments 
or  irregularity  within  the  joint.  Occasionally  the  snapping  may  be 
caused  by  slipping  of  the  biceps  tendon  or  by  displacement  of  the 
external  semilunar  cartilage. 

Treatment. — The  treatment  of  congenital  dislocation  or  sub- 
luxations of  the  knee  consists  in  reposition,  support,  and  massage 
of  the  weak  part.  The  snapping  knee  of  infancy  may  be  supported 
by  a  flannel  bandage,  or,  in  the  more  marked  t^'pe  of  laxity  of 
ligaments,  it  may  be  fixed  for  a  time  in  a  brace.  Complete  recovery 
is  the  rule. 

Congenital  Contraction. — Slight  limitation  of  the  range  of  exten- 
sion of  one  or  both  knees  is  not  infrequent.  As  a  rule  it  is 
easily  overcome  by  massage  and  manipulation.  In  the  more 
extreme  cases  there  may  be  an  accommodative  forward  bending 
of  the  lower  extremity  of  the  femur. 

General  Contractions. — Congenital  contraction  at  the  knees  of 
a  more  marked  and  resistant  form  may  be  combined  with  flexion 
contraction  at  the  hips,  or  it  may  be  one  of  a  series  of  contractions 
at  other  joints.  In  the  latter  instance  other  congenital  deformities, 
such  as  club-hand  or  foot,  or  evidences  of  defective  development 
are  usually  present.  For  example,  certain  joints  may  be  fixed  in 
flexion  or  fixed  in  extension.  In  some  instances  the  contraction  or 
the  partial  anchylosis  appears  to  be  due  simply  to  long-continued 
fixation  in  utero,  and  to  consequent  non-development  of  the  muscles. 
In  others  it  is  caused  by  disease,  as  chonch'odystrophia. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the  contrac- 
tion or  fixation.  In  most  instances,  under  careful  and  continued 
treatment,  the  range  of  motion  may  be  in  great  degree  restored. 

Treatment. — The  treatment  consists  in  regular  massage  and 
manipulation,  with  the  aim  of  increasing  the  range  of  motion. 
Deformity,  if  present,  may  be  rectified  in  the  usual  manner. 

1  Drehmann:  Die  Cong.  Lux.  des  Kniegelenks,  Ztschr.  f.  orthop.  Chir.,  1900, 
Band  \-ii,  Heft  4. 


CHAPTE.R  X.!. 

DISEASES  AND  INJURIES  OF  THE  ANICLE-  AND  TARSAL 

JOINTS. 

TUBERCULOUS    DISEASE    OF    THE    ANKLE-JOINT. 

Disease  of  the  ankle-joint  is  the  third  in  the  order  of  importance, 
although  it  is  far  less  common  than  is  disease  at  the  knee. 

In  five  consecutive  years  1788  cases  of  tuberculous  disease  of  the 
joints  of  the  lower  extremity  were  treated  at  the  out-patient  depart- 
ment of  the  Hospital  for  Ruptured  and  Crippled.  In  54.1  per  cent, 
of  these  the  hip-joint  was  affected;  in  36.2  per  cent,  the  knee-joint, 
and  in  but  9.7  per  cent,  the  ankle-joint. 


Fig.  350. — Tuberculous  disease  of  the  ankle  and  tarsus.    A,  disease  of  the  ankle  and 
subastragaloid  joints.     B,  cavity  in  the  os  calcis  containing  sequestrum. 

Pathology. — ^The  pathology  of  tuberculous  disease  at  the  ankle 
differs  in  no  essential  particular  from  that  of  disease  of  the  hip  and 
knee.  It  does  not,  therefore,  call  for  special  consideration.  It  is 
of  interest  to  note,  however,  that  abscess  is  a  more  common  compli- 
cation at  this  than  at  the  other  joints. 

In  30  final  results  of  disease  at  the  ankle  reported  by  Gibney,i 
abscess  was  present  in  25  (83  per  cent.) .     In  78  final  results  reported 

1  Am.  Jour.  Obst.,  April,  1880. 


456  DISEASES  OF  AXKLE-  AXD   TARSAL  JOIXTS 

by  Prendlsbiu'ger^  abscess  was  present  in  68  (87  per  cent.),  as  con- 
trasted with  a  percentage  of  69  and  51  at  the  knee  and  hip,  respec- 
tively. This  greater  habihty  to  abscess  is  probably  apparent 
rather  than  actual,  since  the  ankle-joint  is  so  superficial  that  fluctua- 
tion may  be  detected  here  that  would  be  overlooked  at  the  hip,  and 
because  an  opening  usually  forms  before  sufficient  time  has  elapsed 
to  permit  of  absorption. 

Situation  of  the  Disease. — Otto  Hahn-  investigated  the  cases  of 
tuberculous  disease  of  the  ankle  and  foot  treated  at  Tubingen  during 
a  period  of  fifteen  years.  These  cases  were  704  in  number  in  685 
patients,  in  19  both  feet  having  been  involved. 

In  309  of  the  cases  the  disease  was  of  the  ankle-joint.  Of  these 
51  per  cent,  were  osteal  in  origin.  The  primary  focus  was  in  the 
internal  malleolus  in  11 ,  the  external  in  7,  in  both  in  5.  It  was  in  the 
external  malleolus  in  11,  the  external  in  7,  in  both  in  5.  It  was  in 
the  astragalus  in  116  cases. 

In  16  instances  the  disease  of  the  ankle  was  secondary  to  primary 
infection  of  the  os  calcis,  and  in  5  cases  both  the  astragalus  and  the 
OS  calcis  were  diseased. 

Of  88  cases  investigated  by  Stich^  the  ankle-joint  was  involved  in 
88  per  cent.,  in  45  per  cent,  the  disease  being  limited  to  this  joint. 
The  astragalonavicular  joint  was  involved  in  29  per  cent.,  and  the 
astragalocalcaneoid  joint  in  36  per  cent. 

Sever-  has  tabulated  2.52  cases  with  references  to  location. 

Location  of  Disease   (by  Operation  or  X-rats). 

Astragalus 74 

Os  calcis 45 

Scaphoid 14 

Cuboid 14 

Tibia  (lower  end) 42 

Fibula  (lo-wer  end)     .       .      .      .       . 19 

Internal  cuneiform 6 

Middle  cuneiform 6 

External  cuneiform 5 

First  metatarsal          12 

Second  metatarsal 5 

Third  metatarsal 4 

Fourth  metatarsal 2 

Fifth  metatarsal         4 

252 
Occurring  in  more  than  1  bone 40      • 

Etiology. — The  etiology  of  tuberculous  joint  disease  does  not 
requhe  fm'ther  comment.  It  may  be  noted,  however,  that  tuber- 
culous disease  at  the  ankle  is  relatively  more  common  in  later  child- 
hood and  adult  life  than  is  the  same  aftection  at  the  knee  and  hip. 

1  Loc.  cit.  2  Beitr.  z.  klin.  Chir.,  1900,  Band  xxvi,  Heft  2. 

'  Beitr.  z.  klin.  Chir.,  xlv,  5S7. 

■*  Joiu".  Am.  Med.  Assn.,  December  17,  1910. 


TUBERCULOUS  DISEASE  OF   THE  ANKLE-JOINT        457 


Of  1000  cases  of  disease  of  the  hip-joint,  12  per  cent,  were  in 
patients  more  than  ten  years  of  age. 

Of  1000  cases  of  disease  of  the  knee-joint,  25  per  cent,  were  in 
patients  more  than  ten  years  of  age. 

Of  339  cases  of  disease  of  the  ankle-joint,  30  per  cent,  were  in 
patients  more  than  ten  years  of  age.^ 

Of  the  339  patients  177  were  males  (52.2  per  cent.);  162  were 
females  (47.8  per  cent.).  The  disease  was  of  the  right  ankle  in  173 
cases;  of  the  left  in  166. 

Age  at  Incipiency  of  Ankle-joint  Disease  in  339  Consecutive  Cases  Treated 
AT  THE  Hospital  for  Ruptured  and  Crippled. 

.  .  .  .  2 

.  .  .  .  3 

.  .  .  .  3 

.  .  .  .  4 

.  .  .  .  4 

.  .  .  .  2 

.  .  .  .  2 

.  .  .  .  0 

.  .  .  .  1 

.  .  .  .  2 

.  .  .  .  1 

.  .  .  .  0 

.  .  .  .  2 

.  .  .  .  2 

.  .  .  .   -    4 

.  .  .  .  1 

.  .  .  .  1 

.  .  .  .  4 

.  .  .  .  2 

.  .  .  .  1 

.  .      .  .  1 


1  year  or  less 

5 

24  years 

old 

2  years  old 

42 

25 

3 

43 

26 

4 

44 

27 

5 

34 

28 

6 

24 

29 

7 

19 

30 

8 

8 

31 

9 

9 

32 

10 

9 

33 

11 

11 

34 

12 

8 

35 

13 

4 

36 

14 

4 

37 

15 

4 

40 

16 

6 

43 

17 

2 

44 

18 

4 

45 

19 

3 

46 

20 

3 

48 

21 

4 

50 

22 

5 

23 

2 

339 


Age  of  the  Patients  Treated  for  Ankle-joint  and  Tarsal  Disease  at 


Tubingen.     (Hahn.) 

Males. 

1  to  10  years 45 

11  to  20  years 149 

21  to  30  years 89 

31  to  40  years 32 

41  to  50  years 37 

51  to  60  years 35 

61  to  70  years 18 

71  to  80  years 6 

81  years 1 

412 


nales. 

Total. 

28 

73 

91 

240 

34 

123 

28 

60 

27 

64 

26 

61 

11 

29 

1 

7 

0 

1 

246 


658 


Four  hundred  and  twelve  of  the  658  patients  were  males  (62  per 
cent.);  246  were  females  (38  per  cent.).  In  27  the  sex  was  not 
stated. 

Symptoms. — The  symptoms  are  usually  subacute  in  character, 
and  are  often  mistaken  for  sprain  or  rheumatism.     In  some  instances 

1  Statistics  from  Hospital  for  Ruptured  and  Crippled. 


458  DISEASES  OF  ANKLE-  AND   TARSAL  JOINTS 

they  appear  to  follow  an  injury,  but  in  the  majority  of  cases  in 
childhood  no  cause  can  be  assigned.  The  ankle  becomes  sensitive  to 
sudden  movements;  the  patient  limps,  and  there  is  complaint  of 
discomfort  after  overuse  and  of  pain  at  night.  The  limp  differs  in 
character  from  that  caused  by  hip  or  knee  disease.  The  patient 
walks  with  the  limb  rotated  outward,  bearing  the  weight  upon  the 
heel  and  upon  the  inner  border  of  the  foot,  active  leverage  "spring" 
being  avoided. 

Primarily  the  symptoms  are  those  of  a  persistent,  somewhat 
painful  disability  at  the  ankle,  causing  stiffness  and  limp;  later 
rff/orm^T/ ^appears . 


Fig.  351. — Tuberculous  disease  of  the  left  ankle. 

Deformity. — The  primary  deformity  of  ankle-joint  disease  in  the 
subacute  cases  is  valgus,  induced  by  a  persistence  of  the  passive 
attitude.  In  more  advanced  cases  it  becomes  equinovalgus,  and 
when  the  limb  is  no  longer  capable  of  supporting  weight,  but  is  held 
pendent,  the  equinus  predominates. 

The  joint  is  usually  somewhat  enlarged.  In  some  instances  the 
swelling  is  uniform;  in  others  it  is  localized  in  front  or  behind  one 
of  the  malleoli.  This  swelling  is  not,  as  a  rule,  like  that  of  simple 
effusion  into  the  joint,  but  the  tissues  have  the  peculiar  elasticity 
characteristic  of  thickening  and  infiltration.  There  is  usually  a 
perceptible  increase  in  the  local  temperature,  and  pressure  directly 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT        459 

upon  the  malleoli  causes  discomfort.  The  voluntary  movements  of 
the  joint  are  restricted,  and  passive  movements  show  the  character- 
istic reflex  muscular  spasm,  limiting  both  dorsal  and  plantar  flexion. 
Subastragaloid  Disease. — If  the  astragalus  is  primarily  diseased, 
the  symptoms  are  usually  first  apparent  in  the  ankle-joint,  but  in 
certain  cases  the  joint  between  the  astragalus  and  the  os  calcis  is 
first  involved.  Disease  at  the  subastragaloid  joint  is  usually  classed 
as  ankle-joint  disease,-  although  the  swelling  is  most  marked  as  a 
point  somewhat  belqw  the  malleoli  (Fig.  352) . 


Fig.  352. — Tuberculous  disease  of  the  subastragaloid  joint. 

In  this  form  forced  lateral  motion  of  the  os  calcis  causes  discomfort 
and  the  range  of  adduction  and  abduction  of  the  foot  is  restricted, 
while  dorsal  and  plantar, flexion  may  be  unrestricted. 

Astragalonavicular  Disease. — If  the  disease  is  limited  to  this  joint 
the  foot  is  usuafly  fixed  in  an  attitude  of  persistent  abduction,  and 
as  the  process  is  usually  of  the  subacute  type  it  may  be  mistaken 
for  rigid  weak  foot. 

Diagnosis. — The  principles  of  differential  diagnosis  of  tubercu- 
lous disease  from  other  affections  have  been  considered  in  detail 
in  the  description  of  disease  of  the  larger  joints. 

In  childhood  a  chronic,  painful  disease  confined  to  a  single  joint  in 
which  motion  is  limited  by  muscular  spasm,  and  in  which  there  is  a 
tendency  to  deformity,  is  almost  certainly  tuberculous  in  character. . 


Fig.  353. — The  epiphyses  of  the  lower  extremities  at  the  age  of  six  years,  showing 
the  effect  of  operative  removal  of  bone  at  the  ankle-joint  for  tuberculous  disease  at 
the  age  of  three  years,  in  causing  subsequent  deformity  of  the  foot  and  shortening 
of  the  limb.    Ossification  is  present  at  birth  in  the  lower  epiphysis  of  the  tibia. 


TUBERCULOUS  DISEASE  OF   THE  ANKLE-JOINT        461 

In  adult  life  also  the  same  statement  applies,  and  distinguishes 
tuberculous  disease  from  rheumatism,  arthritis  deformans,  or  other 
multiple  joint  diseases.  Forms  of  injections  arthritis  may  be  differ- 
entiated by  the  history.  Sprains  or  other  injury  may  be  distin- 
guished by  the  history  of  the  onset  and  by  the  absence  of  local  signs 
of  serious  disease.  In  weak  or  painful  flat-foot  the  symptoms  are 
localized  at  the  mediotarsal  joint.  It  should  be  borne  in  mind,  also, 
that  the  pain  from  a  weak  or  injured  foot  is  felt,  as  a  rule,  only  when 
it  is  in  use;  whereas  in  tuberculous  disease  of  the  bone,  pain  is 
common  when  the  part  is  not  in  use,  particularly  at  night. 

Treatment. — In  disease  of  this,  as  of  other  joints,  functional  rest 
is  indicated.  This  necessitates  fixation  of  the  joints  and  stilting  of 
the  limb,  if  weight-bearing  causes  discomfort.  The  foot  should  be 
fixed  in  a  light  plaster  bandage  extending  from  the  extremities  of 
the  toes  to  the  upper  third  of  the  leg,  at  a  right  angle  with  the  leg 
and  in  an  attitude  of  slight  inversion,  in  order  to  guard  against  the 
tendency  toward  valgus.  This  deformity  is  very  common  after 
the  cure  of  the  disease,  and  it  often  subjects  the  patient  to  the  addi- 
tional discomfort  of  the  weak  foot. 

Reduction  of  Deformity. — If  the  foot  has  become  distorted  before 
the  patient  is  brought  for  treatment,  a  plaster  bandage  may  be 
applied  in  the  attitude  of  deformity,  and  at  the  subsequent  appli- 
cations of  the  dressing,  when  the  muscular  spasm  is  lessened,  the 
malposition  may  be  reduced  by  gentle  manipulation.  In  resistant 
cases  immediate  reduction  of  the  deformity  under  anesthesia  may 
be  advisable.  Throughout  the  entire  course  of  treatment  the  great- 
est attention  must  be  paid  to  the  attitude.  Deformity  is  easily 
prevented,  but  is  often  very  difficult  to  correct,  especially  during 
the  later  stages  of  the  disease,  when  the  tissues  are  infiltrated  and 
sensitive,  and  especially  if  discharging  sinuses  are  present. 

Other  retentive  appliances  may  be  employed,  but  they  are 
inferior  to  a  properly  applied  plaster  support,  which  holds  its  place 
by  accuracy  of  adjustment,  which  most  effectively  prevents  motion, 
and  which  exercises  a  certain  degree  of  compression  upon  and  general 
support  of  the  swollen  joint.  The  bandage  is  usually  renewed  at 
intervals  of  a  month,  but  it  may  be  retained  indefinitely  if  it  is 
properly  protected  by  a  light  shoe  or  slipper.  When  the  disease  is 
no  longer  active  a  light  brace  of  the  type  illustrated  in  the  chapter 
on  Talipes,  to  be  worn  inside  the  shoe,  may  be  substituted  for  the 
plaster  support.  The  Bier  method  of  passive  congestion  may  be 
applied  by  means  of  a  bandage  above  the  knee.  The  adhesive- 
plaster  strapping  may  be  used  beneath  the  plaster  bandage  if  local 
compression  and  more  comprehensive  support  is  desired. 

The  most  satisfactory  brace  to  serve  as  a  stilt  in  connection  with 
the  local  support  is  the  Thomas  brace,  which  has  been  described  in 
the  section  on  Disease  of  the  Knee-joint. 

If   patients  [are    treated  [efficiently    the    discomfort    or    incon- 


462  DISEASES  OF  ANKLE-  AND   TARSAL  JOINTS 

venieiice  attending  the  disease  is  slight.  As  a  rule  the  swelling  of 
the  joint  becomes  more  localized  and  finally  an  abscess  appears 
beneath  the  skin.  It  is  then  advisable  to  remove  the  fluid  and  other 
contents  by  means  of  a  simple  incision.  In  most  instances  a  sinus 
persists  for  a  time.  If  the  discharge  is  slight,  the  part  may  be 
dressed  with  ichthyol,  balsam  of  Peru  or  other  application,  and  the 
whole  enclosed  again  in  the  plaster  bandage;  or,  if  it  be  more  pro- 
fuse, an  opening  may  be  made  and  the  dressing  applied  outside 
the  plaster  bandage.  When  the  stage  of  recovery  is  reached,  stilt- 
ing apparatus  may  be  discarded,  the  patient  being  allowed  to  bear 
the  weight  on  the  foot,  protected  by  the  plaster  bandage  or  other 
support. 

Operative  Treatment. — Early  operation,  especially  of  a  gouging 
character,  involving  the  articulations  should  be  avoided.  An 
efi^ective  operation  of  this  class  often  involves  the  sacrifice  of  bone 
that  would  be  spared  in  the  natural  cure,  and  it  entails  an  irregu- 
larity in  the  growth  and  causes  deformity  in  after-life  that  maybe 
irremediable  (Fig.  353). 

Similar  operations  in  the  treatment  of  fistulee,  or  abscess,  while 
the  tissues  are  thickened  and  edematous  and  while  the  disease 
within  the  joint  is  active,  should  be  postponed  until  the  process  of 
repair  is  more  advanced.  During  the  stage  of  convalescence,  how- 
ever, cure  may  be  hastened  by  the  removal  of  persistent .  foci  of 
disease,  or  sequestra  in  the  bone,  or  tuberculous  tracts  in  the  over- 
lying soft  parts. 

In  the  adult  or  adolescent,  and  in  exceptional  cases  in  childhood, 
operative  treatment  may  be  indicated  when,  for  example,  an  .T-ray 
picture  shows  a  focus  in  a  single  bone  of  the  tarsus.  If  the  disease 
is  confined  to  the  ankle-joint,  astragalectomy  may  assure  the  removal 
of  the  disease  and  the  retention  of  motion. 

The  operation  is  performed  under  the  Esmarch  bandage;  a 
curved  lateral  incision  is  made  passing  beneath  the  external  mal- 
leolus from  the  neighborhood  of  the  tendo-Achillis  to  the  anterior 
aspect  of  the  joint.  The  lateral  and  capsular  ligaments  are  divided, 
after  which  the  foot  may  be  displaced  inward.  The  astragalus  is 
exposed  and  it  may  be  removed  easily  by  dividing  the  ligaments 
about  its  head  and  its  attachments  to  the  os  calcis.  All  the  diseased 
tissue  in  the  soft  parts  and  in  the  bone  must  be  removed  thoroughly. 
If  the  disease  has  not  extended  to  the  tarsus,  and  if  it  seems  to  have 
been  completely  removed,  the  wound  may  be  closed,  but  in  most  cases 
it  should  be  packed  for  a  time  with  gauze.  In  all  cases  the  foot 
should  be  displaced  backward  so  that  the  malleoli  may  rest  upon 
the  anterior  extremity  of  the  os  calcis,  otherwise  calcaneus  deformity 
may  result  as  in  cases  reported  from  Garre's  clinic.^  The  after- 
treatment  is  conducted  as  if  the  operation  had  not  been  performed, 

1  Syring:  Beitr.  z.  klin.  Chir.,  Band  Ixxxvii,  Heft  1. 


TUBERCULOUS  DISEASE  OF   THE   TARSUS  463 

support  and  fixation  being  continued  until  it  is  evident  that  the 
disease  is  cured. 

Removal  of  the  astragalus  does  not  interfere  to  a  marked  extent 
with  the  function  of  the  foot,  nor  does  it  cause  noticeable  deformity. 
As  a  primary  operation,  permitting  inspection  and  the  opportunity 
for  thorough  removal  of  all  disease  in  the  neighboring  parts,  it  should 
always  be  performed  in  preference  to  extensive  gouging,  which  is, 
as  a  rule,  of  little  avail.  It  may  be  mentioned  in  this  connection 
that  motion  in  an  anchylosed  joint  may  be  restored  by  the  removal 
of  the  astragalus. 

Prognosis. — Disease  at  the  ankle  is  not  only  less  common,  but 
it  is  less  dangerous  than  that  of  the  larger  joints,  because^it  isVemote 
from  important  structures,  and  because  there  is  less  opportunity  for 
the  burrowing  of  infected  abscesses.  The  duration  of  the  disease  here 
is,  as  a  rule,  shorter  than  at  the  knee  or  hip,  and  the  final  results  in 
childhood  are  almost  always  excellent.  Often  free  motion  is  retained 
at  the  ankle,  and  even  if  the  astragalus  is  fixed  by  disease  the  mobil- 
ity in  the  other  joints  of  the  foot  is  sufficient  to  compensate  very 
effectively  for  the  anchylosis.  Shortening  of  the  limb  is  of  compara- 
tively little  consequence.  It  is  not  often  more  than  an  inch,  and  it 
may  be  absent.  The  growth  of  the  foot  is  often  considerably 
retarded,  partly  from  disuse  and  partly  because  of  the  destructive 
effect  of  the  disease  upon  the  tarsal  bones. 

Of  29  apparently  final  results  reported  from  the  New  York 
Orthopedic  Hospital^  there  were  15  with  free  motion  without 
deformity.  Limited  motion  without  deformity,  6;  limited  motion 
with  deformity,  2.  There  were  6  deaths  in  a  total  of  50  cases,  21 
of  which  could  not  be  traced.  The  average  duration  of  treatment 
was  four  and  one-sixth  years. 

In  the  30  cases  reported  by  Gibney,  treated  expectantly,  in  which 
the  mechanical  treatment  was  far  from  effective,  6  patients  recovered 
with  normal  motion;  11  with  practically  normal  function.  In  7 
there  was  good  motion.  In  6  there  was  anchylosis,  and  in  3  per- 
sistant valgus.  In  all  the  limb  was  efficient.  In  20  instances  there 
was  no  limp,  and  in  but  1  case  was  it  marked.  In  no  instance  was 
a  crutch,  cane,  or  other  support  used.  The  average  duration  of  the 
disease  was  three  years  and  three  months,  a  minimum  of  one  year, 
a  maximum  of  six  years.  There  were  2  deaths,  of  which  but  1  was 
dependent  upon  the  disease,  septicemia  being  the  cause  assigned, 
though  it  is  stated  that  practically  all  the  bones  of  the  tarsus  were 
involved.     In  this  case  amputation  was  evidently  indicated. 

TUBERCULOUS  DISEASE  OF  THE  TARSUS. 

Tuberculous  disease  of  the  joints  of  the  foot,  not  involving  the 
ankle,  is  not  uncommon. 

'  Humphries  and  Durham:  Jour.  Am.  Med.  Assn.,  January  27,  1917. 


464  DISEASES  OF  ANKLE-  AND   TARSAL  JOINTS 

In  386  of  the  704  cases  reported  by  Hahn,  the  disease  was  hmited 
to  the  foot.  In  141  cases  the  mediotarsal  joint  was  involved;  in 
51  of  these  the  disease  was  confined  to  this  joint;  in  46  the  ankle 
was  involved;  in  29  the  disease  extended  forward  to  the  tarsometa- 
tarsal articulation,  and  in  16  the  three  joints  were  diseased.  In  78 
cases  the  tarsometatarsal  joint  was  involved,  in  33  of  which  the  dis- 
ease did  not  extend  beyond  this  articulation. 

Distribution  among  Individual  Bones. — In  these  cases  the 
distribution  was  as  follows: 


The  astragalus 
The  ealcaneuin 
The  cuboid 
The  scaphoid    . 
The  cuneiform  bones 


170;    disease  confined  to  the  single  bone  in    8 

200;    disease  confined  to  the  single  bone  in  87 

116;    disease  confined  to  the  single  bone  in  18 

82;    disease  confined  to  the  single  bone  in    2 

86;    disease  confined  to  the  single  bone  in    8 

f  in  one-half  of  these  the  disease  was  of 


H4^  ,    ,         ,  ,  Ar       I  the  first  metatarsal,  either  alone  or 

Metatarsal  bones  ...        45;     i  .   •  ^.  ^^,,      ,,  i-    •    • 

in    connection    with    the    adjoining 

[  cuneiform    bone    or    phalanx. 

In  a  total  of  1483  cases,  including  these  and  others  reported  by 
Audry/  Konig,^  Mondan,^  Munch,^  Spengler,^  Yallas,''  Czerny/ 
Dumont,^  Sever,^  the  relative  frequency  of  the  disease  in  the  bones 
of  the  foot  and  ankle  appeared  to  be  as  follows : 


Leg  bones 

.      147,     9.9  per  cent. 

Scaphoid 

124,  8.4  per  cent 

Astragalus 

.      365,24.6 

Cuneiform  bones    . 

126,8.7 

Calcaneus 

.      384,  26.3 

Metatarsus 

137,9.2 

Cuboid 

.      168, 11.4 

Phalanges    . 

22,  1.4 

In  disease  limited  to  the  astragalonavicular  joint  the  swelling 
and  sensitiveness  are  localized  in  front  of  the  ankle  on  the  inner  side 
of  the  foot.  Adduction  is  restricted,  and  the  foot  is  often  fixed  in 
an  attitude  of  persistent  abduction. 

Disease  of  other  bones  or  joints  of  the  tarsus  is  indicated  by  the 
local  swelling  and  sensitiveness. 

Treatment. — Disease  of  the  tarsus  shows  a  marked  tendency  to 
extend  from  one  bone  to  another  until  the  entire  foot  is  involved. 
Consequently  if  an  early  diagnosis  is  made  of  a  distinctly  localized 
process  prompt  removal  of  the  affected  bone  is  indicated;  but  in 
most  instances  the  disease  is  too  extensive  to  permit  of  its  radical 
removal.  In  such  cases  operative  intervention  is  contra-indicated, 
and  the  treatment  by  protection  similar  to  that  employed  in  disease 
of  the  ankle  is  indicated.  In  childhood  the  prognosis  is  very  good 
even  when  the  disease  is  extensive,  but  in  adult  life  amputation  of 
the  foot  may  be  advisable  because  of  the  time  required  to  assure  a 

1  Rev.  de  Chir.,  1891.  2  Schmidt's:  Jahrb.,  1884,  cciv. 

3  Deutsch.  Chir.,  i,  66.  ^  Deutsch.  Ztschr.  f.  Chir.,  1879,  xi. 

5  Ibid.,  1897,  xliv.  «  e  Deutsch.  Chir.,  i,  66. 

'  Volk:  S.    klin.,   v.    No.   76.  «  Deutsch.  Ztschr.  f.  Chir.,  1882,  xvii. 

s  Jour.  Am.  Med.  Assn.,  December  17,  1910. 


INJURIES  OF   THE  ANKLE-JOINT  465 

natural  cure  and  because  an  artificial  leg  provides  a  better  support 
than  a  stiff  and  sensitive  extremity.  Amputation  is  almost  always 
indicated,  if  there  is  coexistent  disease  of  the  lungs. 

KOHLER'S   DISEASE. 

Kohler's  disease^  is  limited  to  the  scaphoid  bone  which  is  somewhat 
enlarged  and  somewhat  sensitive  to  pressure.  In  the  .-c-ray  picture 
the  bone  or  its  ossified  centre  appears  to  be  abnormally  dense, 
shortened  anteroposteriorly  and  correspondingly  broader.  The 
affection  usually  occurs  in  adolescents.     It  causes  a  slight  limp  and 


Fig.  354. — Kohler's  disease. 

is  usually  mistaken  for  flat-foot.  Its  etiology  is  unknown.  In 
some  instances  injury  appears  to  be  an  exciting  cause.  The  symp- 
toms are  transitory  and  a  return  to  a  practically  normal  condition 
under  the  protection  assured  by  a  flat-foot  support  is  the  rule  in  a 
year  or  more. 

INJURIES  OF  THE  ANKLE-JOINT. 

Sprain.-— The  ankle  is,  from  its  position,  especially  liable  to 
injiu-y;  in  fact,  the  term  "sprain"  is  popularly  associated  with  this 
joint. 

Etiology. — A  sprain  is  most  often  caused  by  an  unguarded  move- 
ment, by  which  the  foot  is  turned  suddenly  inward  or  outward,  with 
sufficient  force  to  injure  the  synovial  membrane,  to  rupture  some  of 
the  fibres  of  the  muscles,  to  strain  tendons  and  tendon  sheaths,  and 
even  to  rupture  ligaments.  If  the  foot  is  twisted  inward  the  injury 
is  most  marked  on  the  outer  side  of  the  joint;  if  outward,  on  the 
inner  side  of  the  ankle.  In  the  slighter  degrees  of  sprain  the  injury 
may  be  confined  to  the  tissues  about  the  joint,  but  in  most  instances 

1  Stummei:  Fort's  auf  d.  Geb.  d'Rontgenstrahlen,  xvi,  342;  Schultze:  Arch.  f. 
Hin.   Chir.,   c,   No.   2. 

30 


466  DISEASES  OF  ANKLE-  AXD   TARSAL   JOINTS 

there  is  effusion  Avithin  the  capsule,  even  hemorrhage  when  injury 
has  been  severe. 

Symptoms. — The  immediate  symptoms  of  sprain  are  pain,  often 
intense,  of  a  throbbing  cliaracter,  swehing,  heat,  and  in  many 
instances  discoloration  of  the  surrounding  parts,  even  extending 
over  the  leg  and  foot. 

Treatment. — If  an  opportunity  for  immediate  treatment  is  offered, 
the  swelling  and  the  eff'usion  of  blood  may  be  restrained  by  wrapping 
the  limb  from  the  toes  to  the  knee  with  a  thick  layer  of  absorbent 
cotton  and  bandaging  it  firmly.  As  much  compression  being 
exercised  as  the  comfort  of  the  patient  will  allow ;  the  thick  covering 
restrains  motion  and  the  elastic  pressure  prevents  swelling.  The 
stockinette  bandage  (Fig.  356)  may  be  used  for  the  same  purpose. 
If  the  injiu"y  has  been  severe  and  if  the  part  is  very  sensitive  to 
motion  or  jar,  the  joint  may  be  fixed  in  a  light  plaster  bandage. 


Fig.  355. — A  method  of  applying  adhesive-plaster  strapping  for  sprain  of  the  ankle. 

This  may  be  cut  down  the  front  to  permit  massage  of  the  foot, 
ankle,  and  leg,  which  is  of  great  service  in  hastening  the  absorption 
of  the  effusion. 

The  use  of  hot  air,  hot  and  cold  water,  and  static  electricity,  and 
the  like  are  of  service  also  in  relieving  the  discomfort  and  more 
especially  in  stimulating  the  circulation,  upon  which  repair  depends. 

By  far  the  most  effective  treatment  during  the  stage  of  recovery 
and  as  an  immediate  application  for  sprains  of  slighter  degree  is  the 
adhesive-plaster  strapping  which  has  been  popularized  by  Gibney. 
His  method  is  as  follows:  Strips  of  adhesive  plaster  about  three- 
quarters  of  an  inch  in  width  and  from  nine  to  eighteen  inches  in 
length  are  prepared.  A  long  strip  is  placed  with  its  centre  beneath 
the  heel,  and  the  two  ends  are  carried  upward  over  the  malleoli,  to 
a  point  at  the  junction  of  the  middle  and  lower  thirds  of  the  leg.  A 
second  strip  is  placed  at  the  posterior  extremity  of  the  heel,  and  the 


INJVRIES  OF   THE  ANKLE-JOINT  467 

two  ends  are  carried  forward  somewhat  beyond  the  tarsometa- 
tarsal junction  on  either  side.  Another  strip  is  then  placed  by  the 
side  of  the  first,  and  the  fourth  by  the  side  of  the  second,  until  the 
entire  ankle  is  smoothly  covered,  except  for  a  space  about  two  inches 
in  width  directly  on  the  front  of  the  ankle.  One  takes  particular 
care  to  make  the  plaster  fit  well  about  the  malleoli  and  reinforces  it 
at  the  points  of  greatest  sensitiveness.  A  light  bandage  is  then 
applied  and  the  patient  is  encouraged  to  use  the  foot  in  walking. 
The  plaster  may  be  applied  in  a  variety  of  ways;  a  satisfactory 
method  is  as  follows,  after  the  preliminary  massage  for  the  purpose 
of  reducing  the  swelling :  One  end  of  a  strip  of  adhesive  plaster  about 
three  feet  long  and  three  inches  wide  is  applied  to  the  lateral  aspect 
of  the  leg  just  below  the  knee-joint;  it  is  carried  down  the  side  of 
the  leg  over  the  malleolus,  beneath  the  heel  and  arch,  and  up  the 
other  side  to  a  point  opposite  the  beginning  where  it  is  fixed  by  a 


Fig.  356. — The  stockinette  bandage.     An  effective  means  of  reducing  swelling  and 
protecting  the  sensitive  joint  to  be  used  in  combination  with  massage. 

circular  band  about  the  calf.  If  the  sprain  is  of  the  outer  side  of  the 
ankle,  sufficient  tension  is  made  upon  the  outer  half  of  the  plaster 
to  hold  the  foot  slightly  abducted.  If,  as  is  more  common,  the  sprain 
is  of  the  inner  side,  the  inner  half  is  drawn  firmly  beneath  the  arch, 
carrying  the  foot  toward  inversion  so  that  all  strain  may  be  removed 
from  the  sensitive  part.  This  band  of  plaster  is  reinforced  by  one  or 
more  laps  so  that  the  lateral  aspect  of  the  ankle  is  completelycovered. 
And  in  addition  the  entire  ankle  is  then  enclosed  with  narrow,  over- 
lapping strips  which  cover  all  the  tissues  well  beyond  the  sensitive 
area.  The  foot  and  leg  are  then  bandaged  to  assure  the  adhesion 
of  the  plaster.  When  the  joint  is  firmly  held  by  the  supporting 
plaster  the  patient  can,  as  a  rule,  walk  with  comfort;  and  he  is 
encouraged  to  do  so,  for  functional  use,  provided  it  does  not  cause 
additional  injury,  is  the  most  effective  stimulant  of  the  circulation; 
thus  the  patient  applying,  as  it  were,  an  automatic  massage,  cures 
himself. 


468  DISEASES  OF  ANKLE-  AND   TARSAL   JOINTS 

As  the  swelling  subsides  the  plaster  strapping  Avrinkles,  and  it 
must  be  renewed,  about  three  applications  being  required,  as  a  rule, 
the  last  of  which  is  allowed  to  remain  until  all  of  the  symptoms  have 
disappeared.  Vigorous  massage  before  applying  the  new  dressing 
is  of  service  in  hastening  the  cure.  It  is  perhaps  needless  to  state 
that  preliminary  shaving  of  the  part  will  add  to  the  comfort  of  the 
patient.^ 

Chronic  Sprain. — A  chronic  sprain  may  be  the  result  of  an 
inefficiently  treated  acute  injury,  in  which  an  improper  attitude 
originally  assumed  to  spare  the  sensitive  part  finally  becomes 
habitual.  In  other  instances  persistent  disability  may  be  the  result 
of  fixation  of  the  joint  for  too  long  a  time  in  splints.  Such  disuse 
causes  atrophy  of  the  muscles  and  of  the  bones  as  well,  while  the 
effused  material  within  and  without  the  joint  remains  because  of 
the  imperfect  circulation.  The  same  disability  may  follow  simple 
disuse  of  the  injiu-ed  part.  It  is  more  often  observed  in  nervous 
individuals  who  exaggerate  the  importance  of  the  injm-y  and  the 
discomfort  that  it  causes.  In  such  cases  the  limb  may  be  discolored 
by  venous  congestion,  the  foot  may  be  edematous  and  the  move- 
ments may  be  limited  by  adhesions  or  by  muscular  adaptation  to 
the  habitual  attitude. 

In  other  instances  the  original  injm-y  may  have  caused  a  slight 
subluxation  of  the  astragalus,  sufficient  to  throw  the  foot  into  an 
attitude  of  abduction,  in  which  it  has  become  fixed  by  the  secondary 
changes  in  the  muscles  and  ligaments.  In  some  cases  of  this  class 
the  original  sprain  was  at  the  mediotarsal  or  at  the  subastragaloid 
joint,  and  its  effect  has  been  tramnatic  weak  foot.  It  may  be  stated, 
also,  that  many  of  the  so-called  sprains  of  the  ankle  are  simply 
injm-ies  of  a  weak  foot,  a  disability  to  which  the  treatment  should 
be  directed.     (See  the  Weak  Foot.) 

Treatment. — Treatment  must  be  conducted  with  the  aim  of  restor- 
ing the  normal  range  of  motion  and  so  supporting  the  part  that 
normal  functional  use  may  be  permitted.  If  adhesions  have  formed 
and  if  the  foot  is  persistently  held  in  an  abnormal  attitude,  forcible 
manipulation  under  anesthesia  may  be  required  as  a  preliminary 
treatment,  followed  by  fixation  for  a  time  in  a  plaster  bandage,  in 
the  attitude  directly  opposed  to  that  which  has  been  habitual.  In 
this  class  of  cases  the  habitual  attitude  is  usually  one  of  equino- 
valgus;  the  foot  should  be  fixed  for  a  time,  therefore,  in  a  plaster 
bandage  in  a  position  of  extreme  varus,  at  a  right  angle  with  the 
the  leg,  and  upon  it  the  patient  is  encouraged  to  bear  his  weight 
both  in  standing  and  walking.  When  all  discomfort  has  disap- 
peared, a  support,  usually  a  light  leg  brace  to  prevent  lateral  motion, 
and  if  the  arch  is  depressed  a  foot  plate  also,  should  be  worn  for  a 

1  According  to  Beardsley  adhesive  plaster  may  be  easily  removed  by  applying  oil 
of  wintergreen  to  its  surface.  This  permeates  its  substance  and  dissolves  the  adhesive 
substance. 


TENOSYNOVITIS  469 

time.  The  most  effective  curative  agent  is  functional  use,  but  mas- 
sage, hot  air,  passive  manipulation,  and  exercises  are  valuable 
accessories. 

Injuries  of  this  class  are  very  amenable  to  treatment,  conducted 
with  the  aim  of  restoring  normal  function,  if  proper  support  is 
provided  during  the  period  of  pain  and  weakness. 

Fracture  of  the  Tarsal  Bones. — If  the  injury  has  been  severe, 
especially  a  fall  from  a  height,  fracture  of  the  tarsal  bones  should  be 
considered  as  a  possible  complication  of  the  sprain.  One  should 
compare  the  relative  height  of  the  malleoli  above  the  heel  on  the 
two  sides,  since  a  lessened  distance  is  proof  of  fracture  of  the 
astragalus  or  os  calcis  or  both.  Thickening  at  this  point  and  slight 
lateral  displacement  of  the  foot  are  confirmatory  signs. 

In  fractures  of  this  class  the  upper  articulating  surface  of  the 
astragalus  often  retains  its  normal  contour.  So  that  dorsal  and 
plantar  flexion  may  be  but  slightly  restricted  while  adduction  and 
abduction  movements  proper  to  the  subastragaloid  joints  are  lost. 

Treatment. — In  all  suspicious  cases  a:-ray  pictures  should  be  taken 
and  if  fracture  and  displacement  are  present,  one  should  under 
anesthesia  attempt  to  mould  the  foot  to  an  approximately  normal 
contour,  especially  at  the  arch.  This  is  important  if  the  os  calcis 
is  fractured,  as  one  of  the  fragments  is  often  forced  downward  into 
the  tissues  of  the  sole.  A  plaster  bandage  is  then  applied.  After 
consolidation  of  the  fracture  passive  movements  should  be  per- 
sistently employed  particularly  in  adduction.  As  a  rule  an  arched 
foot  plate  should  be  worn  during  the  period  of  recovery.  In  certain 
instances  operative  treatment  is  indicated  to  remove  projecting 
fragments  of  bone,  or  the  entire  astragalus  if  the  joint  is  disorganized. 

Fracture  of  the  other  bones  of  the  tarsus  is  uncommon  and  the 
accident  is  of  comparatively  slight  importance. 

TENOSYNOVITIS. 

The  sheaths  of  the  tendons  about  the  ankle-joint,  if  involved  in 
a  sprain  of  the  ankle,  may  cause  persistent  interference  with  func- 
tion; or  strain  of  a  tendon  and  of  its  sheath  may  induce  disability 
if  the  joint  is  uninjured.  The  symptoms  of  acute  tenosynovitis 
are  discomfort  on  motion  of  the  affected  tendon,  and  this  motion 
may  be  accompanied  by  a  peculiar  creaking  which  is  apparent  on 
palpation  and  usually  there  is  slight  local  swelling  and  sensitiveness 
to  pressm-e  about  the  affected  part. 

At  the  ankle-joint  all  the  tendons  are  provided  with  sheaths;  on 
the  front  of  the  foot  are  three — the  sheath  of  the  tibialis  anticus, 
which  extends  from  a  point  about  two  inches  above  the  extremity 
of  the  malleolus  to  the  navicular  bone  (Fig.  357) ;  that  of  the  exten- 
sor longus  hallucis,  from  the  annular  ligament  to  the  head  of  the 
first  metatarsal,  and  the  common  sheath  for  the  extensor  communis 


470 


DISEASES  OF  ANKLE-  AXD  TARSAL   JOINTS 


digitorum,  extending  from  a  point  abont  half  an  inch  abo\'e  the 
malleoh  to  about  one  inch  below  the  annular  ligament.     Behind 


Fig.  358. — The  internal  annular  ligament  of 
the  ankle  and  the  artificially  distended  synovial 
membrane  of  the  tendons  which  it  confines. 
(Gerrish's  Anatomy.) 


Fig.  357. — The  anterior  annu- 
lar ligament  of  the  ankle  and  the 
sj^novial  membranes  of  the  ten- 
dons beneath  it  artificially  dis- 
tended.     (Gerrish's  Anatomj-.) 


Fig.  359. — The  external  anntilar  ligament  of 
the  ankle  and  the  artificially  distended  syno\dal 
membranes  of  the  tendons  which  it  confines. 
(Gerrish's  Anatomy.) 


the  internal  malleolus  are  the  common  sheaths  of  the  tibialis  posti- 
cus and  flexor  longus  digitorum,  beginning  about  an  inch  above  the 


TENOSYNOVITIS 


471 


extremity  of  the  malleolus  and  extending  to  the  astragalonaviciilar 
junction  and  that  of  the  flexor  longus  hallucis  of  about  the  same 
extent  (Fig.  357).  Behind  the  outer  malleolus  is  the  sheath  of  the 
two  peronei,  beginning  one  inch  above  the  malleolus,  dividing  into 
two  portions  for  the  two  tendons  and  ending  just  behind  the  tuber- 
osity of  the  fifth  metatarsal  bone  (Fig.  358) . 

Treatment. — Simple  traumatic  tenosynovitis  should  be  treated 
by  rest  and  by  compression.  An  effective  treatment  is  strapping 
with  adhesive  plaster,  so  applied  as  to  prevent  the  movements  of 
the  feot  that  cause   discomfort.     In  more  painful  and  persistent 


Fig.  360. — Painful  swellings  about  the  ankles,  common  in  overweighted  subject. 


cases  a  plaster  bandage  to  assure  absolute  rest  may  be  necessary. 
Cautery  applied  over  the  affected  part  is  of  service.  Chronic 
tenosynovitis  may  follow  injury  or  it  may  be  the  result  of  gonor- 
rhea or  other  infectious  disease.  In  chronic  cases  when'  the  pahia- 
tive  treatment  is  ineffective,  thorough  removal  of  the  affected 
sheath  is  indicated.     (See  Achilobursitis.) 

Tuberculous  Tenosynovitis. — A  persistent  and  increasing  swelling 
of  a  tendon  sheath  always  suggests  tuberculous  disease.  In  such 
instances  the  sac  is  thickened  and  often  contains  the  so-called  rice 
bodies.  Prompt  and  complete  removal  of  the  diseased  sheath  is 
indicated,  and  by  this  means  a  permanent  cure  may  be  attained 
in  most  instances. 


472  DISEASES  OF  ANKLE-  AND   TARSAL  JOINTS 

SWELLING  ABOUT  THE  ANKLES. 

Occasionally  often  in  combination  with  weak  feet  there  are  dis- 
tinct swellings  about  the  ankles.  The  most  common  is  in  front  of 
the  external  malleoli.  This  is  apparently  a  bursa-like  formation, 
or  in  some  instances  an  extrusion  from  the  joint  made  up  of  synovial 
and  fatty  tissue.  In  most  cases  the  patients  are  fat  and  the  appar- 
ent cause  is  overweight. 

The  patients  usually  complain  of  weakness  and  discomfort.  The 
treatment  aside  from  reduction  of  weight,  and  support  for  the  weak- 
ened arch,  is  massage,  strapping  and  bandaging.  The  operative 
removal  of  the  swollen  tissue  is  indicated  in  obstinate  cases. 


CHAPTER   XII. 

DISEASES  AND  INJURIES  OF  THE  ARTICULATIONS  OF 
THE  UPPER  EXTREMITY. 

TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT. 

Disease  at  the  shoulder  is  very  uncommon  in  childhood.  In  a 
total  of  453  cases  of  tuberculous  disease  treated  at  the  Vanderbilt 
clinic  210  were  cases  of  Pott's  disease.  In  6  of  the  remaining  243 
cases  the  disease  was  of  the  shoulder-joint  (2.5  per  cent.). 

In  1883  consecutive  cases  of  joint  disease — Pott's  disease  being 
excluded — treated  in  the  out-patient  department  of  the  Hospital 
for  Ruptured  and  Crippled  in  a  period  of  five  years,  the  shoulder- 


FiG.  361. — Section  of  the  shoulder-joint  at  the  age  of  eight  years.  (Schuchardt.) 
Ossification  appears  in  the  epiphysis  of  the  head  of  the  humerus  at  the  end  of  the 
first  year;  a  second  point  appears  in  the  greater  tuberosity  during  the  second  year. 
These  unite  between  the  fourth  and  sixth  years.  Ossification  is  complete  between 
the  eighteenth  and  twentieth  years.  The  angle  formed  by  the  head  and  shaft  is  from 
130°  to  140°.  The  range  of  motion  at  the  joint  between  adduction  and  abduction  is 
about  90  and  between  flexion  and  extension  (anteroposterior  movement)  somewhat 
less. 

joint  was  involved  in  38  instances  (2  per  cent.).  Of  1900  cases  of 
joint  disease  treated  at  Billroth's  clinic,  the  shoulder  was  involved 
in  14,  or  less  than  1  per  cent.  At  the  Boston  Children's  Hospital 
but  17  cases  were  recorded  in  a  total  of  7474  cases  of  tuberculous 
disease  of  spine  and  joints,  illustrating  its  infrequency  in  early  life.^ 
Pathology. — The  disease  usually  begins  in  the  head  of  the 
humerus.     In  32  observations  on  adults  recorded  by  Mondan  and~ 

1  Sever:  Boston  Med.  and  Surg.  Jour.,  March  24,  1910. 


474    DISEASES  AND  INJURIES  OF   THE  UPPER  EXTREMITY 

Andry/  the  primary  disease  was  of  the  head  of  the  humerus  in  23 
cases,  of  the  humerus  and  scapula  in  4,  of  the  scapula  alone  in  1, 
and  in  3  instances  it  appeared  to  be  primarily  synovial.     ■ 

In  the  majority  of  cases  abscess  forms  and  appears  near  the 
anterior  insertion  of  the  deltoid  muscle.  In  advanced  cases  the  tissues 
of  the  axilla  and  of  the  adjoining  thorax  may  be  infiltrated  and  per- 
forated by  numerous  sinuses.  Not  infrequently  the  disease  is  of 
the  form  called  caries  sicca,  in  which  there  is  no  swelling,  but  pro- 
gressive destruction  of  the  head  of  the  humerus  by  granulation 
tissue.  This  form  is  characterized  by  extreme  muscular  atrophy 
and  by  practical  anchylosis. 


Fig.  362. — Tuberculous  disease  of  the  shoulder-joint,  showing,  the  atrophy. 

Townsend^  made  a  detailed  report  on  21  cases  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled  during  the  years  1889  to  1893.  Ten 
of  these  were  less  than  ten  years  of  age;  7  were  between  ten  and 
tM'enty,  and  4  were  more  than  twenty.  The  youngest  patient  was 
three  and  a  half  and  the  age  of  the  oldest  was  thirty-five  years.  In 
5  cases  the  disease  was  secondary  to  disease  of  other  parts;  in  1 
•case  to  Pott's  disease;  in  2  to  hip  disease,  and  in  2  to  disease  of  the 
knee-joint. 


1  Rev.  de  Chir.,  1892. 


Tr.  Am.  Orthop.  Assn.,  vii. 


TUBERCULOUS  DISEASE  OF   THE  SHOULDER-JOINT     475 

Age  at  Incipiency  of  Disease  at  the  Shoulder-joint  in  Sixty-two  Consecutive 
Cases  Treated  at  the  Hospital  for  Ruptured  and  Crippled. 


1  year  or  less    . 

.      .      1 

13  years  old 

.      .      .        3 

2  years 

old        .      . 

.      .     6 

15 

.      .      .        2 

3 

.      .      1 

18 

.      .      .        3 

4 

.      .     3 

19 

.      .      .        5 

5 

.      .     3 

20 

.      .      .        4 

6 

.      .      1 

23 

.      .      .        1 

7 

.      .     3 

26 

.      .      .        2 

8 

.       .      4 

27 

.      .      .        1 

9 

.      .      6 

34 

.      .      .        1 

10 

.      .      1 

48 

.      .      .        1 

11 

.      .      5 

56          " 

.      .      .        1 

12   '      " 

.      .      4 

— 

Total      .      .      .      62  ■ 
Males,  38;  females,  24;  right,  35;  left,  27. 

Symptoms. — ^The  history  of  the  case  will  indicate  the  persistent 
and  progressive  character  of  the  disability,  but  the  symptoms 
characteristic  of  tuberculous  disease  are  far  less  marked  at  the 
shoulder  than  at  other  joints.  This  is  explained  by  the  fact  that 
the  upper  extremity  is  not  subjected  to  weight-bearing  and  because 
the  mobility  of  the  scapula  upon  the  thorax  lessens  the  injury  caused 
by  unguarded  movements  of  the  arm.  This  movement  of  the 
scapula  masks  the  interference  with  the  function  of  the  joint,  and 
the  strain  caused  by  overuse  is  lessened  by  the  unconscious  restraint 
of  motion.  In  fact,  even  when  anchylosis  is  present  the  patient 
may  think  that  motion  is  but  moderately  restricted. 

The  symptoms  of  the  disease  may  be  classified  as  j)Ciin,  sensitive- 
ness, restriction  of  motion,  atrophy. 

There  is  usually  a  dull  ache  about  the  joint,  with  occasional 
neuralgic  pain  referred  to  the  elbow  and  arm.  The  discomfort  is 
increased  by  movements  that  pass  beyond  the  limits  allowed  by  the 
mobility  of  the  scapula,  especially  on  attempting  to  rotate  the 
humerus,  as  in  clothing  one's  self  or  brushing  the  hair.  The  joint 
is  sensitive  to  pressure;  thus  the  patient  finds  that  he  cannot  lie 
on  the  affected  side  at  night. 

On  examination  the  limitation  of  motion  caused  by  muscular 
spasm  will  be  evident  if  the  scapula  is  fixed. 

Pressure  about  the  head  of  the  humerus  usually  causes  pain, 
and  in  many  instances  local  heat  and  swelling  are  present.  The 
atrophy  of  the  shoulder  muscles  is  often  extreme  and  that  of  the 
other  muscles  of  the  limb  is  well  marked. 

As  has  been  stated,  abscess  is  a  common  accompaniment  of  the 
disease,  and  in  such  cases  the  tissues  about  the  joint  are  swollen 
and  infiltrated.  In  other  instances  there  is  progressive  destruction 
of  the  head  of  the  humerus  without  abscess  formation  (caries  sicca). 
In  cases  of  this  type  the  flattening  of  the  shoulder  may  be  so  extreme 
as  to  be  mistaken  for  subcoracoid  dislocation. 

Treatment. — The  treatment  of  the  disease  here  as  elsewhere  is 
rest.     To  assure  absolute  functional  rest  the  wrist  should  be  attached 


476    DISEASES  AND  INJURIES  OF  THE  UPPER  EXTREMITY 

to  the  neck  by  a  sling,  the  elbow  being  flexed  to  an  acute  angle; 
the  arm  is  then  fixed  to  the  thorax  by  a  bandage.  Local  rest  and 
compression  may  be  still  further  assured  by  strips  of  adhesive 
plaster  applied  over  the  shoulder  and  extending  to  the  back  and 
chest;  or  a  shoulder-cap  of  leather  or  plaster  may  be  employed. 
This  method  of  fixing  the  bare  arm  to  the  chest  is  the  only  one  that 
assures  continuous  rest,  as  changes  of  the  clothing  necessitate  move- 
ment of  the  joint.     During  the  acute  phases  of  the  disease  the  arm 


Fig.  363. — Tuberculous  disease  of  the  shoulder-joint. 

may  be  supported  in  the  attitude  of  right  angular  abduction  by 
means  of  a  brace  or  in  moderate  abduction,  by  a  triangular  splint 
or  by  a  thick  pad  of  cotton  in  the  axilla.  Direct  traction  is  not 
often  employed,  as  support  of  the  pendent  limb  is  usually  preferred 
by  the  patient. 

If  the  focus  of  disease  seems  to  be  localized  in  the  x-vay  picture, 
an  exploratory  operation  for  its  early  removal  may  be  indicated. 
Arthrectomy  in  younger  subjects  may  be  indicated  when  suppura- 
tion is  persistent  or  when  for  other  reasons  it  may  seem  best  to 


TUBERCULOUS  DISEASE  OF   THE  ELBOW-JOINT        477 

attempt  to  remove  the  diseased  area.  Excision  of  the  joint  or  a 
plastic  operation  may  be  advisable  for  the  purpose  of  restoring 
motion  in  adolescent  or  adult  ,cases. 

Prognosis. — The  duration  of  the  disease  appears  to  be  from  two 
to  five  years.  The  death-rate  is  higher  than  in  disease  of  the  joints 
of  the  lower  extremity,  because  a  larger  proportion  of  the  patients 
are  adults,  and  in  this  class  tuberculosis  of  the  lungs  is  not  an  infre- 
quent complication. 

It  is  impossible  to  speak  positively  of  the  results  of  the  conserva- 
tive treatment  of  disease  of  the  shoulder.  The  disease  is  uncommon, 
and  protection  is  almost  never  applied  in  the  incipient  stage,  nor 
efficiently  and  persistently  employed  to  the  end.  The  ordinary 
result  is,  therefore,  anchylosis,  usually  of  the  fibrous  rather  than  of 
the  bony  variety. 

If  the  disease  appears  in  early  life  the  growth  of  the  limb  may  be 
seriously  interfered  with;  an  inch  or  more  of  shortening  from  this 
cause  is  not  uncommon. 

TUBERCULOUS  DISEASE  OF  THE  ELBOW-JOINT. 

Tuberculous  disease  of  the  elbow-joint  is  the  fourth  in  order  of 
frequency,  preceding  the  shoulder  and  the  wrist.  Of  1883  consecu- 
tive cases  of  joint  disease  treated  at  the  Hospital  for  Ruptured  and 
Crippled  56  were  of  the  elbow. 

Pathology. — ^The  primary  disease  is  in  most  instances  osteal,  as 
in  92.8  per  cent,  of  the  cases  investigated  by  Scheimpflug,  44  in 
number.^  The  original  focus  of  infection  is  somewhat  more  often 
of  the  ulna  than  of  the  humerus.  Of  the  ulna  the  olecranon  pro- 
cess, and  of  the  humerus  the  external  condyle  appear  to  be  the 
points  of  election.  Disease  of  the  head  of  the  radius  is  compara- 
tively infrequent. 

Age  at  Incipiency  of  Disease  at  the  Elbow-joint  in  Fifty-nine  Consecutive 
Cases  Treated  at  the  Hospital  for  Ruptured  and  Crippled. 

1  year  or  less 2  13  years  old         .....        3 

2  years  old 5  14         "  2 


3 
4 
5 
6 
7 
8 
9 
10 
11 


8  15  "                1 

5  17  "                1 

5  19  "                1 

4  21  "                 1 

8  23  "                1 

1  25  ■"                 2 

2  29  "                 1 

5  — 

1  Total        ...  59 

Males,  28;  females,  31;  right,  27;  left,  32. 


Occurrence. — In  119  cases  reported  by  Oilier  the  olecranon  was 
involved  in  73,  the  humerus  in  33,  and  the  radius  in  12  instances. ^ 

1  Festschrift    fiir    Billroth,    1892. 

2  Karewski:  Chir.  Krank.  des  Kindesalter,  268. 


47S     DISEASES  AXD  I XJ TRIES  OF   THE  UPPER  EXTREMITY 

And  in  the  cases  investigated  by  Kiimmer^  and  ^Nliddledorpt,-  the 
uhia  was  more  often  the  seat  of  the  primary  disease  than  was  the 
hmnerus,  but  in  81  cases  treated  in  Konig's  chnic  the  primary  dis- 
ease was  of  the  humerus  in  -13,  of  the  olecranon  in  36,  and  of  the 
radius  in  2  instances.-^ 

Symptoms. — The  symptoms  are  those  of  a  chronic,  persistent, 
destructive  disease — pain,  local  sensitiveness  and  swelling,  stiffness, 
deformity,  atrophy. 


Fig.  364. — Tuberculous  disease  of  the  elbow-joint. 

The  pain  is  usually  localized  at  the  elbow.  It  is  increased  by 
sudden  movements,  and  as  the  bones  are  so  superficial  there  is 
usually  local  sensitiveness  to  pressure,  most  marked  over  the  seat 
of  the  disease.  In  the  early  stage  the  swelling  is  slight,  and  it  is  of 
the  peculiar  elastic  character  due  to  thickening  of  the  tissue  rather 
than  to  effusion  within  the  capsule,  but  as  the  disease  progresses 
the  joint  assumes  the  peculiar  spindle  shape  characteristic  of  white 
swelling.  The  degree  of  elevation  of  the  local  temperature  depends 
upon   the   activity  of  the  disease.     The  most  important  physical 

1  Deutsch.  Ztschr.  f.  Chir..  xxvii.  -  Arch.  f.  klin.  Chir.,  xxxiii. 

3  Konig:  Lehrbuch  Spec.  Cliir..  Berlin,  1900.  Sever  reports  50  cases  in  a  total 
of  747-4  cases  of  spine  and  joint  tuberculosis  treated  at  the  Boston  Children's  Hos- 
pital.   Boston  Med.  and  Surg.  .Jour.,  Maj-  19,  1910. 


TUBERCULOUS  DISEASE  OF   THE  ELBOW-JOINT        479 

sign  is  the  restriction  of  motion  due  to  the  characteristic  muscular 
spasm  which  becomes  evident  when  the  Umit  of  painless  motion  is 
passed.  The  limitation  of  extension  and  flexion  gradually  increases, 
and  finally  the  limb  becomes  fixed  in  an  attitude  midway  between 
flexion  and  extension,  with  the  forearm  in  an  attitude  between 
pronation  and  supination.  This  is  the  characteristic  deformity 
of  the  disease. 

Atrophy  of  the  muscles  of  the  arm  and  forearm  is  present,  cor- 
responding to  the  intensity  and  duration  of  the  disease  and  to  the 
functiogal  disability  of  the  joint. 


Fig.  365. — Tuberculous  disease  of  the  elbow-joint;  the  stage  of  recovery. 


Treatment. — The  treatment  here  as  elsewhere  consists  essentially 
in  placing  the  joint  at  rest  in  the  attitude  at  which  anchylosis  or 
limitation  of  motion  will  least  inconvenience  the  patient,  and  at  the 
elbow-joint  this  is  practically  at  right  angular  flexion  (Fig.  365). 

In  the  treatment  of  young  children  the  wrist  may  be  attached 
closely  to  the  neck  by  means  of  a  sling,  in  an  attitude  of  acute  flexion 
at  the  elbow  (the  Thomas  method)  within  the  clothing.  Or  a  light 
plaster  splint  may  be  used  to  fix  the  wrist,  being  supported  by  a  sling. 
This  enables  the  patient  to  dress  himself  without  moving  the  joint 
and  at  the  same  time  protects  it  from  injury.  Other  forms  of  splints 
may  be  employed,  but  the  plaster  support  answers  every  purpose. 


480    DISEASES  AND  INJURIES  OF   THE  UPPER  EXTREMITY 

It  should,  of  course,  extend  from  the  axilla  to  the  wrist,  and  in 
sensitive  cases  it  may  include  the  hand  also.  The  Bier  treatment 
may  be  easily  applied  and  its  effects  should  be  tested  in  all  cases. 

Reduction  of  Deformity. — In  many  instances  the  arm  is  fixed  in  the 
semiextended  attitude  when  the  patient  is  brought  for  treatment. 
A  simple  and  effective  means  of  reducing  deformity  in  childhood  is 
that  suggested  by  Thomas.  When  it  is  impossible  to  bring  the  wrist 
to  the  neck,  one  bends  the  neck  toward  the  %^Tist  and  attaches  the 
two  by  a  bandage  which  the  patient  is  unable  to  remove.  From  this 
uncomfortable  attitude  the  patient  can  free  himself  only  b}'  drawing 
the  forearm  toward  the  neck  and  thus  reducing  the  deformity.  At 
the  next  visit  the  same  procedure  is  repeated,  until  finally  the  elbow 
is  flexed  to  the  required  degree.  A  permanent  sling  may  be  con- 
structed of  a  leather  ^^Tist-band  and  a  tube  of  leather  to  pass  about 
the  neck,  through  which  the  bandage  may  be  drawn ;  thus  the  pres- 
sure on  the  wrist  and  neck  may  be  lessened.  In  the  very  resistant 
cases  reduction  of  deformity  under  anesthesia  may  be  required  but 
this  is  not  often  necessary. 

Operative  Treatment. — In  some  instances  it  is  possible  to  remove 
small  foci  of  disease  from  the  humerus,  or  from  the  adjoining  bones 
before  the  joint  is  involved.  The  position  of  the  disease  may  be 
indicated  by  sensitiveness  or  swelling,  and  in  older  subjects  a 
Roentgen  pictm-e  may  demonstrate  its  position  accurately. 

Excision  of  the  Elbow. — Excision  is  often  advisable  in  adolescent 
or  adult  life,  because  by  this  procedure  the  disease  may  be  removed 
in  most  instances,  and  because  motion  may  be  assured. 

Oschman  has  recently  investigated  the  final  results  of  the  opera- 
tion performed  on  this  class  at  Kocher's^  clinic  at  Berne,  1872-1897, 
In  40  of  45  cases  the  operation  was  performed  for  tuberculous  dis- 
ease. There  were  no  deaths  referable  to  the  operation.  Of  the 
entire  number  of  cases  15  were  dead,  but  11  of  these  survived  the 
operation  for  from  five  to  twenty  years.  Eight  of  the  deaths  were 
due  to  tuberculosis,  2  to  other  causes,  and  in  5  the  cause  of  death 
was  unknown.  In  96  per  cent,  of  the  cases  the  local  disease  was 
cured.  In  68  per  cent,  of  the  cases  the  patients  were  able  to  use  the 
limb  at  hard  labor,  and  in  the  others  it  was  efficient  for  light  work. 
In  6  cases  there  was  subluxation  or  luxation;  in  5  the  joint  was  not 
firm.  In  59  per  cent,  the  motions  were  practically  normal.  In  11 
per  cent,  the  joint  was  anchylosed. 

Prognosis. — ^If  the  case  is  treated  at  an  early  stage  the  prog- 
nosis in  childhood  is  good.  The  duration  of  treatment  may  be 
estimated  at  two  years  or  more,  and  a  fair  range  of  motion  will  be 
preserved  in  half  the  cases.  Anchylosis  in  the  right-angled  posi- 
tion does  not,  however,  seriously  inconvenience  the  patient,  provided 
the  cure  is  absolute.     The  loss  of  growth  is  usually  less  than  when 

1  Arch.  f.  klin.  Chir.,  Band  Ix,  Heft  2. 


TUBERCULOUS  DISEASE  OF   THE   WRIST-JOINT         481 

the  upper  epiphysis  of  the  humerus  has  been  destroyed,  the  final 
disproportion  depending,  of  course,  upon  the  age  of  the  patient 
and  upon  the  degree  of  function  that  is  preserved. ^ 


TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT 

Disease  of  the  wrist-joint  is  very  uncommon  in  childhood.  In 
a  total  of  3105  cases  of  tuberculous  disease  treated  in  the  out- 
patient department  of  the  Hospital  for  Ruptured  and  Crippled 
during 'a  period  of  five  years,  98  were  of  the  upper  extremity,  and  in 
but  4  of  these  was  the  wrist-joint  involved.  Of  43  cases  in  which 
the  joint  was  resected  by  Oilier,  the  youngest  patient  was  thirteen 
years  of  age. 


Fig.  366. — TulDerculous  disease  of  the  wrist  and   knee-joints,  showing  the  charac- 
teristic deformities  in  neglected_cases  of  a  severe  type.  ' 

Of  990  cases  of  disease  of  the  joints  in  childhood,  reported  by 
Karewski,  the  wrist  was  involved  in  31.- 

Disease  _of_  the  wrist  in  older  subjects  is  less  infrequent,  although 
at  all  ages  it  is  rare  as  compared  with  disease  in  other  joints.  Tuber- 
culous disease  of  the  metacarpus  and  phalanges  (spina  ventosa)  is, 
however,  far  more  common. 


1  In  38  fina    results  of  non-operative  treatment  reported  by  Sever  good  motion 
was  retained  in  12.     In  16  anchylosis  was  present.      (Loc.  cit.) 

2  Chir.  Krank.  des  Kindesalter,  Berlin,  1894. 
,31 


482    DISEASES  AND  INJURIES  OF   THE  UPPER  EXTREMITY 


Age  at  Incipiency  of  Disease  at  the  Wrist-joint  in  Eighteen  Consecutive 
Cases  Treated  at  the  Hospital  for  Ruptured  and  Crippled. 


2  vears  old 

6' 

9 
12 
14 
16 
17 


1 

19  years  old 

1 

20 

1 

25 

2 

26 

1 

27 

2 

1 

Total 
Males,  11;  females,  7;  right,  12;  left,  6. 


2 
2 
2 
1 

18 


Symptoms. — ^The  symptoms  of  tuberculous  disease  of  the  wrist 
are,  as  in  other  situations,  2^'^in,  local  siceUing,  and  sensitiveness, 
limitatio7i  of  motion,  caused  by  muscular  spasm,  and  atrophy.  In 
advanced  cases  the  hand  is  usually  flexed  somewhat  upon  the  arm. 


Fig.  .367. — Tuberculous  disease  of  the  right  wrist-joint,  showing  the  swelling  and  the 

limitation  of  motion. 

Treatment. — The  treatment  of  this,  as  of  other  joints,  is  func- 
tional rest,  with  support  in  the  attitude  in  which  anchylosis  or  limita- 
tion of  motion  will  cause  the  least  inconvenience.  A  light  plaster 
bandage  extending  from  the  elbow  to  the  tips  of  the  fingers,  applied 
over  a  flannel  bandage  drawn  as  tight  as  the  comfort  of  the  patient 
will  permit,  is  a  satisfactory  support;  or  a  leather  splint  or  other 
form  of  appliance  may  be  used.  The  hand  should  be  supported  in 
an  attitude  of  moderate  dorsal  flexion,  which  will  permit  the  flexor 
muscles  to  close  the  fingers  easily  if  the  -^Tist  becomes  fixed  by  the 
disease.  If  flexion  deformity  is  present  it  should  be  corrected 
slightly  at  each  application  of  the  bandage,  until  the  desired  attitude 
is  attained  (Fig  368).  The  flannel  bandage  exercises  a  certain 
degree  of  compression  upon  the  \\Tist,  which  seems  to  be  of  benefit, 


Fig.  368. — ^Treatment  of  tuberculosis  of  the  wrist-joint  by  plaster  of  Paris,  showing 

the  proper  attitude. 


Fig.  .369. — -Tuberculous  disease  of  the  carpus. 


Fig.  370. — Tuberculous  disease  of  the  left  wrist-joint.  The  irregularity  and  the 
diminished  size  of  the  carpal  bones  indicate  the  extent  of  the  destructive  process. 
The  patient,  the  mother  of  the  child  with  Pott's  disease  (Fig.  10),  died  soon  after 
from  tuberculosis  of  the  lungs. 


484    DISEASES  AND  INJURIES  OF   THE  UPPER  EXTREMITY 

and  in  certain  instances  this  compression  and  fixation  may  be  still 
further  increased  by  the  application  of  adhesive  plaster.  Bier's 
treatment  by  passive  congestion  may  be  applied,  and  according 
to  reports  it  is  especially  eflBcacious  in  this  situation.  When  the 
disease  of  the  Joint  is  quiescent,  or  in  the  stage  of  recovery,  the 
bandage  or  splint  may  be  shortened  to  permit  the  use  of  the  fingers. 
Prognosis. — The  prognosis  as  regards  function  in  cases  treated 
promptly  in  childhood  should  be  good.  In  the  adult  cases  wrist- 
joint  disease  seems  to  be  very  often  accompanied  by  disease  of  the 
lungs;  thus  the  prognosis  as  to  life  is  bad.  In  this  class  of  cases 
early  excision  is  usually  recommended,  with  amputation  as  a  final 
resort. 

SPINA  VENTOSA. 

Central  disease  of  the  long  bones  of  the  foot  and  hand  is  the  most 
common  form  of  diaphyseal  tuberculosis.  While  the  cortical 
substance  is  destroyed  from  within  it  is  often  replaced  in  part  by  a 
formation  of  periosteal  bone  from  without,  which  in  turn  may  be 
destroyed  by  the  advancing  disease.  In  the  early  cases  the  affected 
bone  is  enlarged,  spindle-shaped,  and  is  somewhat  sensitive  to 
pressure.  At  this  stage  repair  may  take  place  with  but  little  ulti- 
mate change  from  the  normal,  but  in  many  instances  the  bone  is 
perforated  and  in  part  destroyed,  the  neighboring  joint  is  involved, 
and  the  finger  becomes  stunted  and  distorted. 

In  159  cases  tabulated  by  Karewski,^  the  metacarpal  bones  were 
diseased  in  65  instances;  the  phalanges  in  57;  the  metatarsal  bones 
in  29,  the  phalanges  of  the  toes  in  8.  In  a  number  of  instances 
several  of  the  bones  and  larger  joints  were  involved  also  (159  cases 
in  135  patients). 

The  disease  is  more  common  in  the  early  years  of  life,  84  of  the 
135  patients  being  four  years  of  age  or  less,  38  of  these  being  less 
than  two. 

Spina  ventosa  of  the  phalanges  may  be  treated  by  rest  and  com- 
pression, and  both  splinting  and  compression  may  be  assured  by 
adhesive-plaster  strapping.  If  the  joint  is  involved  amputation 
of  the  finger  may  be  indicated,  because  of  the  distortion  and  loss 
of  growth  that  may  be  expected.  Tuberculous  disease,  limited  to 
a  single  bone  of  the  carpus  or  metacarpus,  may  be  treated  by 
operative  removal  of  the  disease. 

PERIARTHRITIS    OF    THE    SHOULDER— STIFF    AND    PAINFUL 

SHOULDER. 

Under  the  title  of  scapulohumeral  periarthritis,  Duplay,-  in  1872, 
described  a  painful  affection  of  the  shoulder  induced  by  injury 

1  Chir.  Krank.  des  Kindesalter,  Berlin,   189-4. 

2  Arch.  gen.  de  med.,  Paris,  1872. 


PERIARTHRITIS  OP  THE  SHOULDER  485 

dependent  upon  an  inflammation  of  the  bursa  lying  between  the 
deltoid  and  supraspinatus  and  infraspinatus  muscles  and  the  coraco- 
acromial  ligament.  But  under  this  title  are  now  included  a  number 
of  affections  that  cause  similar  symptoms  in  which  it  would  appear 
that  the  interior  of  the  joint  is  not  involved. 

Symptoms. — In  a  typical  case  of  so-called  periarthritis  the 
patient  complains  of  a  dull  pain  about  the  joint  and  sensitiveness 
to  pressure  just  below  the  acromion  process  or  over  the  bicipital 
groove  and  occasionally  a  swelling  is  evident  on  the  anterior  aspect 
of  the  joint.  The  pain  is  increased  by  motion,  particularly  by 
abduction  or  by  rotation  of  the  arm.  In  mild  cases  only  extensive 
motion  causes  pain,  but  in  most  instances  there  is  a  constant  sensa- 
tion of  discomfort  which  is  increased  to  acute  pain  by  sudden  move- 
ments or  jars.  The  part  becomes  sensitive  to  pressure,  so  that  the 
patient  avoids  lying  on  the  shoulder  at  night.  In  certain  instances 
the  pain  may  radiate  about  the  shoulder  and  down  the  arm,  and 
there  may  be  weakness  and  numbness  of  the  fingers.  Gradually 
the  passive  movements  of  the  joint  are  diminished  in  range,  and 
atrophy  of  the  shoulder  muscles  appears. 

These  symptoms  usually  pass  as  "rheumatism,"  but  there  is  no 
fever,  no  involvement  of  other  joints,  no  swelling,  and  as  a  rule, 
no  general  sensitiveness  to  pressure,  as  is  usual  when  the  synovial 
membrane  of  the  joint  is  affected.  In  certain  instances  the  symptoms 
follow  injury,  strain  or  exposure  to  cold,  or  they  appear  without 
apparent  cause.  In  typical  cases  the  symptoms  are  due  to  inflam- 
mation of  the  subdeltoid  bursa,  as  originally  described  by  Duplay. 
This  bursa  lies  beneath  the  deltoid  muscle,  separating  it  from  the 
joint.  According  to  Baer  it  is  about  the  size  of  a  silver  half-dollar 
(Fig.  371).  It  sends  a  prolongation  beneath  the  acromion  process 
and  the  coraco-acromion  ligament.  If  the  bursa  is  enlarged  it  pre- 
sents a  mechanical  obstacle  to  abduction  and  in  acute  cases  one 
that  is  sensitive  to  pressure.  Symptoms  somewhat  similar  may  be 
caused  by  inflammation  of  the  subcoracoid  bursa,  lying  between  the 
tip  of  the  coracoid  and  the  capsule,  extending  to  and  over  the  lesser 
tuberosity.  In  such  cases  rotation  is  more  directly  restrained  than 
abduction.  By  tenosynovitis  of  the  biceps  tendon  as  suggested  by 
local  sensitiveness  at  the  bicipital  groove,  and  by  the  creaking  sen- 
sation at  this  point  when  the  muscle  is  in  use.  By  arthritis  of  the 
acromioclavicular  articulation  indicated  by  local  pain  and  sensi- 
tiveness at  this  articulation.^  By  injury  or  rupture  of  the  supra- 
spinatus tendon,^  and  doubtless  by  unclassified  injury,  subluxation 
at  the  shoulder  and  intra-articular  disease  in  the  incipient  stage.  It 
is  probable  also  that  in  some  cases  the  nerves  in  the  neighborhood 
of  the  joint  may  be  secondarily  implicated  in  an  inflammation  of 
bursse,  or  directly  injured  by  the  original  traumatism,  if  such  pre- 

1  Sievers:  Deutsch.  Ztschr.  f.  Chir.,  cxxix,  583. 

2  Codman:  Boston  Med.  and  Surg.  Jour.,  July  27,  1911. 


486    DISEASES  AND  INJURIES  OF   THE  UPPER  EXTREMITY 

ceded  the  symptoms.     Thus  neuritis  may  add  to  the  discomfort 
and  prolong  the  disability. 

Treatment. — Dm*ing  the  acute  and  painful  stage  the  arm  should 
be  kept  at  rest.  Cautery  may  be  applied  and  the  joint  should  be 
enclosed  in  adhesive-plaster  strapping,  and  if  the  weight  of  the  limb 
causes  discomfort  it  shoidd  be  supported.     In  certain   instances 


tension  on  the  sensitive  part  may  be  lelaxed  by  supporting  the  arm 
in  an  attitude  of  slight  abduction.  When  the  acute  symptoms  have 
subsided  passive  movements,  massage,  and  static  electricity  are  of 
ser\dce.  Voluntary  exercises  should  be  employed  when  they  no 
longer  aggravate  the  s^Tuptoms.  In  the  cases  of  long  standing  in 
which  motion  is  very  much  restricted,  apparently  by  adhesions 


SPRAIN  OF  THE  WRIST  487 

without  the  joint,  passive  movements  under  anesthesia  to  the 
extremes  of  the  normal  range  are  usually  of  benefit.  In  such  cases 
it  may  be  well  to  support  the  limb  for  a  time  in  the  abducted  attitude 
to  prevent  the  formation  of  the  adhesions.  Afterward  passive 
motion,  massage  and  exercise  must  be  employed  to  prevent  the 
return  of  the  restriction.  If  these  cases  are  treated  carefully  in  the 
early  stage,  recovery  is  usually  rapid,  but  if  neglected  the  symptoms 
may  persist  indefinitely.  ^ 

Operative. — In  cases  in  which  it  is  evident  that  the  symptoms 
are  catlsed  by  effusion  within  the  bursa,  the  fluid  may  be  removed 
by  aspiration.  In  chronic  cases  open  operation  may  be  required. 
An  incision  about  two  inches  in  length  is  made  through  the  anterior 
fibres  of  the  deltoid  muscle.  The  sac  is  opened,  its  contents 
removed,  and  if  practicable  its  walls  should  be  dissected  from  the 
neighboring  tissues.  Brickner^  has  called  attention  to  the  fact  that 
calcareous  deposits  are  usually  not  in  the  bursa  but  in  the  sheath 
of  the  supraspinatus  tendon  lying  beneath  it.  These  deposits, 
induced  by  injury  of  the  tendon,  often  form  rapidly  and  should  be 
removed  through  an  incision  at  the  base  of  the  bursa.  The  arm 
should  then  be  supported  in  the  abducted  attitude  or,  as  Brickner 
has  suggested,  attached  to  the  head  of  the  bed  which  is  raised  on 
blocks  so  that  the  tendency  of  the  body  to  slide  downward  assures 
the  elevated  position  of  the  arm.  By  this  treatment  the  period  of 
stiffness  and  discomfort  is  materially  shortened. 

CHRONIC  BURSITIS. 

Chronic  bursitis  at  the  shoulder- joint  is  comparatively  infrequent. 
The  bursse  most  often  involved  are  the  coracoid,  the  subscapular, 
and  the  subdeltoid.  Of  these  the  last  is  the  most  often  affected. 
Sixteen  cases  have  been  reported  by  Blauvelt,^  and  three  others  by 
Ehrhardt.'*  The  enlarged  bursa  forms  a  fluctuating  swelling  most 
noticeable  on  the  anterior  and  outer  aspect  of  the  shoulder,  the 
symptoms  being  discomfort,  weakness,  and  limitation  of  motion 
of  the  arm.  The  disease  is  usually  tuberculous  in  character,  and 
it  should  be  treated  by  complete  removal  of  the  sac  if  possible. 

SPRAIN  OF  THE  WRIST. 

This  is  a  very  common  accident.  The  most  effective  treatment 
is  the  adhesive-plaster  strapping  applied  about  the  metacarpus, 
wrist,  and  lower  half  of  the  forearm.  If  the  pain  on  motion  is  severe 
sufficient  plaster  is  applied  to  splint  the  part  and  to  limit  move- 

1  Codman:  Boston  Med.  and  Surg.  Jour.,  May  31,  1906;  Baer:  Johns  Hopkins 
Hosp.  Bull.,  No.  195. 

2  Interstate   Med.   Jour.,   April,    1915. 

5  Beitr.  z.  klin.  Chir.,  xxii.  4  Arch.  f.  klin.  Chir.,  Ix. 


488    DISEASES  AND  INJURIES  OF  THE  UPPER  EXTREMITY 

ment  to  the  point  of  comfort.  If  the  injury  is  of  a  sHghter  grade 
the  compression  and  support  of  a  single  layer  of  plaster  is  usually 
sufficient.  This  dressing  prevents  strain,  and  yet  it  permits  a 
certain  degree  of  functional  use,  which  is  the  most  effective  means 
of  restoring  a  joint  to  its  normal  condition  by  hastening  the  absorp- 
tion of  the  effused  material  within  and  without  the  injured  part. 

Chronic  Sprain. — Persistent  weakness  and  stiffness  may  follow 
treatment  of  a  sprain  by  splints  or  when  for  any  reason  disuse  of 
function  has  been  long  continued.  In  many  instances,  however, 
the  sprain  was  in  reality  a  fracture  or  displacement  of  the  carpus. 
All  chronic  sprains,  therefore,  should  be  examined  by  means  of  the 
.I'-rays  in  order  that  the  presence  or  absence  of  more  extensive 
injury  may  be  determined. 

The  treatment  is  similar  to  that  of  the  acute  sprain:  protection 
from  injury,  and  functional  use  to  the  extent  of  which  the  part  is 
capable.  With  this,  passive  congestion,  massage,  hot  air,  and 
electricity  or  other  form  of  local  stimulation  may  be  employed  with 
advantage.  The  same  treatment  is  indicated  when  the  joint  is  stiff 
and  painful  as  the  result  of  rheumatism  or  other  inflammation, 
provided  the  stage  of  recovery  has  been  reached. 

TENOSYNOVITIS. 

Acute. — Tenosynovitis  more  especially  of  the  flexor  tendons  is 
common  at  the  wrist-joint.  It  is  usually  induced  by  strain  or  over- 
use of  a  muscle  or  muscular  group. 

Movements  of  the  muscles  that  are  involved  cause  discomfort, 
and  there  is  usually  local  sensitiveness  and  a  creaking  sensation  on 
palpation  over  the  affected  tendon  sheath.  The  same  symptoms 
with  more  sensitiveness  to  direct  pressure  may  be  caused  by  inflam- 
mation of  the  peritendinous  tissues.  The  adhesive-plaster  strap- 
ping, so  applied  as  to  exert  compression  and  to  prevent  the  motion, 
that  causes  discomfort,  is  the  most  effective  treatment. 

Chronic. — Chronic  tenosynovitis,  causing  progressive  enlarge- 
ment of  a  tendon  sheath,  with  accompanying  symptoms  of  weakness 
and  discomfort,  is  usually  tuberculous  in  character.  In  such  cases 
the  diseased  part  should  be  promptly  removed.  If  the  disease  is  of 
long  standing,  extending  into  the  palm  of  the  hand  it  may  be  advis- 
able to  simply  evacuate  the  contents,  including  the  rice  bodies, 
through  an  incision.  An  astringent  solution  may  be  injected,  and 
after  its  removal  the  incision  may  be  closed.  Pressure  is  then 
applied,  with  the  aim  of  securing  partial  adhesions  of  the  apposed 
surfaces. 


CHAPTER  XIII. 
DEFORMITIES  OF  THE  UPPER  EXTREMITY. 

CONGENITAL  DISLOCATION  OF  THE  SHOULDER. 

This  may  occur  in  two  forms,  one  in  which  there  is  actual  mis- 
placement before  birth,  and  the  other  in  which  a  dislocation  is 
caused  by  violence  at  birth.  In  either  case  the  displacement  is 
almost  always  backward  upon  the  dorsum  of  the  scapula  (sub- 
spinous). Thus  the  arm  is  abducted  and  rotated  inward,  and  the 
head  of  the  displaced  bone  may  be  felt  in  its  abnormal  position. 
Cases  of  congenital  displacement  in  other  directions  are  recorded, 
but  these  are  so  unusual  as  to  be  of  little  practical  importance.^ 

True  primary  displacements  of  either  variety  are  comparatively 
uncommon,  many  of  the  reported  cases  being  secondary  to  the 
habitual  malposition  induced  by  obstetrical  paralysis  (Fig.  372). 
According  to  Porter,^  29  cases  are  recorded  in  literature,  in  at  least 
half  of  which  the  diagnosis  is  doubtful.  It  is,  of  course,  apparent 
that  both  displacement  and  paralysis  may  be  coincident  and  caused 
by  injury  at  birth. 

OBSTETRICAL  PARALYSIS. 

Partial  or  complete  paralysis  of  the  muscles  of  the  arm  may  be  a 
result  of  difficult  or  protracted  labor.  It  may  be  induced  by  direct 
pressure  on  the  brachial  plexus,  but  most  often  it  is  caused  by  trac- 
tion on  the  body  or  the  head,  or  by  violent  twists  of  the  neck  during 
delivery.  It  is  a  comparatively  common  injury,  69  new  cases 
having  been  registered  at  the  Hospital  for  Ruptured  and  Crippled 
in  1915,  39  of  these  being  less  than  one  year  of  age.  In  rare  instances 
the  paralysis  may  be  bilateral.  In  some  cases  the  nerve  roots  may 
be  torn  apart,  in  others  the  injury  may  be  principally  to  the  sheath 
causing  hemorrhage,  and  in  the  process  of  repair  scar  tissue  forms 
which  presses  upon  the  nerve  elements.  The  fifth  and  sixth  roots 
are  most  often  injured,  consequently  the  common  form  of  paral^is 
is  the  upper  arm  type,  involving  the  deltoid,  the  supra-  and  intra- 
spinati,  the  biceps,  coracobrachialis,  the  supinators  of  the  forearm 
and,  in  part,  the  pectoralis  major.  Thus,  the  power  of  abduction 
and  external  rotation  at  the  shoulder,  of  flexion  and  supination  of 
the  forearm  is  lost  and  the  arm  hangs  in  an  attitude  of  inward  rota- 
tion with  pronated  forearm.     If  the  injury  is  more  severe  the  entire 

1  Scudder:  Am.  Jour.   Med.   Sc,   February,   1898. 

2  Tr.  Am.  Orthop.  Assn.,  1900,  xiii. 


490 


DEFORMITIES  OF   THE    UPPER  EXTREMITY 


arm  may  be  involved,  or  disability,  such  as  T\Tist-drop  or  weakness 
of  the  flexor  group,  may  be  associated  with  the  upper  arm  form  of 
paralysis. 

In  a  group  of  460  cases,  400  were  of  the  upper  arm  type,^  and  in 
SI  cases  operated  on  by  Sharpe,-  the  fifth  and  sixth  roots  were  injured 
in  (32,  the  seventh  in  21,  the  eighth  and  first  dorsal  in  19. 

In  rare  instances  the  hiunerus  may  be  dislocated,  or  the  upper 
epiphysis  may  be  displaced,  or  the  clavicle  fractured. 


Fig.  372, 


-Congenital  dislocation  of  the  left  humerus,  illustrating  the  characteristic 
attitude. 


Eventually  under  the  influence  of  unbalanced  muscular  action, 
the  head  of  the  hiunerus  is  displaced  backward,  subluxated,  so  that 
the  arm  is  abducted  on  the  scapida,  flexed  forward  and  rotated 
inward.  All  movements  are  restricted  by  the  accommodative 
changes  m  the  capsule  and  other  tissues,  and  in  later  years  the 
condition  ma^'  be  easilv  mistaken  for  true  congenital  dislocation. 


1  Sever:  Am.  Jour.  Orthop.  Surg.,  August,   1916. 

2  Surg.,  GjTiec.  and  Obst.,  Januarj%  1917. 


OBSTETRICAL  PARALYSIS  491 

Whether  cases  reported  as  congenital  displacement  of  the  humerus 
are  secondary  to  paralysis  or  not,  it  is  evident  that  all  cases  of 
obstetrical  paralysis  should  be  carefully  examined  with  regard  to  a 
complicating  dislocation,  and  that  the  secondary  deformity  induced 
by  paralysis  should  be  prevented. 

Treatment. — During  the  first  month  after  birth  the  shoulder  of 
the  paralyzed  arm  is  often  somewhat  swollen,  and  motion  may 
cause  pain.  In  such  cases  rest  is  indicated.  The  arm  should  be 
placed  against  the  side,  and  the  hand,  with  the  fingers  extended, 
should  be  supported  on  the  chest  beneath  the  clothing.  When  the 
primary  sensitiveness  has  subsided,  each  of  the  joints  of  the  extrem- 
ity should  be  moved  systematically  to  the  limit  of  the  normal  range 
of  motion  several  times  in  a  day.  For  example,  the  humerus  should 
be  hyperextended  and  rotated  outward  at  the  shoulder;  the  forearm 
should  be  supinated  and  the  wrist  and  fingers  should  be  extended, 
if  they  are  involved  in  the  paralysis.  The  muscles  should  be  mas- 
saged, and  the  arm  should  be  supported  by  a  sling,  or  preferably 
in  an  attitude  of  abduction  at  the  shoulder  and  supination  at  the 
elbow  by  a  light  splint.  Recovery  may  be  complete,  although  it 
is  often  delayed  for  many  months.  As  a  rule  traces  of  the  injury 
are  evident  in  atrophy  of  muscles,  particularly  of  the  deltoid,  and 
a  certain  weakness  of  the  arm  persists,  even  though  no  actual 
paralysis  remains. 

In  many  instances  recovery  is  but  partial,  the  arm  is  weak,  cer- 
tain muscles  are  paralyzed,  and  there  is  much  restriction  of  move- 
ment at  the  shoulder.  The  growth  of  the  member  is  retarded,  the 
upper  extremity  of  the  humerus  is  atrophied,  the  acromion  process 
may  be  bent  downward,  and  as  has  been  mentioned,  the  attitude 
is  that  characteristic  of  posterior  dislocation.  Not  infrequently, 
j,lthough  the  actual  paralysis  is  slight,  the  disability  is  extreme 
because  of  the  displacement  which  restricts  movement  and  causes 
noticeable  deformity.  The  first  essential  in  treatment,  therefore, 
is  to  replace  the  head  of  the  humerus  in  the  proper  position,  and  to 
overcome  all  restrictions  to  normal  motion.  This  applies  to  the 
congenital  as  well  as  to  the  acquired  disability. 

Reduction  of  Deformity. — The  principles  of  the  treatment  of  the 
displaced  humerus  are  to  reduce  the  deformity,  to  fix  the  part  for  a 
time  sufficient  to  prevent  relapse,  to  restore  function  so  far  as  may 
be  by  systematic  passive  motion,  and  by  exercise.  The  method 
employed  by  the  author  with  success  is  somewhat  similar  to  the 
Lorenz  treatment  of  congenital  dislocation  at  the  hip.^ 

The  child  having  been  anesthetized,  is  brought  to  the  edge  of  the 
table.  The  shoulder  is  grasped  firmly  with  one  hand  in  order  to 
restrain  the  movements  of  the  scapula,  and  with  the  other  the  arm 
is  drawn  upward  and  backward  over  the  fulcrum  of  the  thumb, 

1  Whitman:  Jour.  Ment.  and  Nerv.  Dis.,  1904;  Ann.  Surg.,  July,  1905. 


7 


492 


DEFORMITIES  OF   THE   UPPER  EXTrEMITV 


which  hes  behind  the  joint.  This,  the  so-called  pump-handle 
movement,  alternately  relaxing  and  stretching  the  contracted  parts, 
is  carried  out  over  and  over  again  with  slowly  increasing  force,  the 
aim  being  to  force  the  head  of  the  bone  forward,  and  thus  to  thor- 
oughly stretch  the  anterior  part  of  the  capsule.  When  this  has  been 
accomplished  there  is  a  distinct  depression  behind,  and  the  head  of 
the  humerus  projects  in  front,  at  a  point  below  its  proper  position. 


Fig.  373. — The  characteristic  attitude  Fig.  374. — Typical  subluxation  at 

of  inward  rotation  and  pronation  in  ob-         the  shoulder    second.' ry   to    obstet- 
stetrical  paralysis  in  infancy.  rical    paralysis.       The    patient  was 

treated  successfully  by  the  method 
described. 

One  then  attempts  to  overcome  the  abduction  and  to  force  the 
head  upward  by  changing  the  grasp  on  the  scapula  and  using  the 
thumb  in  the  axilla  as  a  fulcrum.  When  the  arm  can  be  carried 
across  the  chest  to  the  normal  degree  of  adduction,  the  final  and 
often  most  difficult  part  of  the  process,  namely,  to  stretch  the 
tissues  sufficiently  to  permit  the  proper  degree  of  outward  rotation, 
is  undertaken.  This  is  best  accomplished  by  flexing  the  forearm 
and  using  this  to  exert  leverage  on  the  humerus,  care  being  taken, 
of  course,  to  avoid  the  danger  of  fracture.  When  the  head  of  the 
bone  has  been  replaced,  it  will  be  noted  that  the  tension  on  the 


OBSTETRICAL  PARALYSIS  493 

anterior  tissues  causes  flexion  of  the  forearm;  this  must  be  overcome 
in  the  same  manner,  and,  finally,  the  limitation  to  complete  supina- 
tion. The  extremity  is  then  fixed  in  the  overcorrected  attitude  by 
means  of  a  plaster  support  which  includes  the  thorax.  That  is, 
the  arm  is  drawn  backward  so  that  the  head  of  the  humerus  is  made 
prominent  anteriorly,  the  forearm  is  flexed  and  turned  outward  to 
the  frontal  plane,  while  the  hand  is  placed  in  extreme  supination, 
the  upper  arm  lying  against  the  lateral  thoracic  wall. 


Fig.  375. — The  deformity  of  obstetrical  paralysis  in  adolescence. 

In  the  very  resistant  cases  it  is  impracticable  to  complete  the 
operation  at  one  sitting.  When,  therefore,  as  much  force  has  been 
exercised  as  seems  wise,  a  plaster  bandage  is  applied  to  hold  the  arm 
in  an  intermediate  position  with  the  head  of  the  femur  forced  for- 
ward, and  after  an  interval  of  two  or  more  weeks  the  further  cor- 
rection is  undertaken.  In  the  treatment  of  older  subjects  the  forcible 
manipulation  may  be  preceded  or  supplemented  by  division  of 
resistant  parts.     This,  however,  is  not  usually  necessary. 


494 


DEFORMITIES  OF   THE   UPPER  EXTREMITY 


As  has  been  stated  when  the  head  of  the  bone  is  forced  forward  a 

distinct  depression  and  evident  relaxation  of  the  tissues  is  noted 
on  the  posterior  aspect  of  the  joint.  The  object  of  the  fixation  is  to 
permit  the  contraction  of  the  posterior  wah  of  the  capsule  and  the 
obliteration  of  the  old  articulation,  consequently,  the  part  must 
be  fixed  for  a  period  of  at  least  three  months.  ^Yhen  the  plaster 
bandage  is  removed,  the  after-treatment  is  of  great  importance. 
This  consists  of  daily  passive  forcible  movements  to  the  extreme 
limits  in  the  directions  formerly  restricted,  namely,  outward  rota- 
tion, backward  extension,  and  eventuallv  abduction  of  the  humerus 


Fig.  376. — The  shoulder  spica  as  applied  after  the  reduction  of  the  deformity  of 
obstetrical  paralysis  showing  the  palm  of  the  hand  directed  backward,  indicating  the 
overcorrection  of  inward  rotation  and  pronation.  At  the  next  dressing  the  arm 
will  be  brought  to  the  side  of  the  trunk  with  the  forearm  turned  outward  to  a  right 
angle. 

and  supination  and  extension  of  the  forearm.  For  in  all  these  cases 
there  is  a  strong  tendency  to  a  return  in  some  degree  to  the  original 
posture.  When  motion  has  become  fairly  free,  the  disabled  member 
must  be  regularly  exercised  and  reeducated  in  functional  use. 
Under  this  treatment  the  weakened  and  almost  completely  atro- 
phied muscles  usually  gain  surprisingly  in  power  and  ability,  and  the 
longer  it  is  continued  the  better  will  be  the  final  result.  Even  if 
the  muscles  about  the  shoulder  are  paralyzed  the  ability  and  appear- 
ance of  the  arm  are  greatly  improved  by  the  reduction  of  the 
deformity. 


OBSTETRICAL  PARALYSIS  495 

If  the  contractions  are  resistant  an  open  operation  is  indicated 
as  modified  by  Sever  from  that  of  Fairbank.^  An  incision  is  made 
between  the  deltoid  and  the  pectoraKs  major.  The  tendon  of  the 
latter  is  divided  and  further  outward  rotation  brings  the  insertion 
of  the  subscapularis  lying  upon  the  joint  capsule  into  view.  When 
this  is  cut  the  resistance  to  outward  rotation  may  be  easily  over- 
come by  manipulation.  Deformity  of  the  acromion,  if  it  interferes 
with  the  movement  of  the  humerus,  may  be  overcome  by  osteotomy. 
The  arm  is  then  fixed  in  plaster  in  the  manner  described. 

Repair  of  Obstetrical  Injury  to  the  Brachial  Plexus. — It  is  evident 
that  if  "repair  of  the  ruptured  or  otherwise  injured  cords  of  the 
brachial  plexus  does  not  take  place,  recovery  is  impossible.  If 
in  spite  of  protection  in  the  manner  described,  there  is  no  evidence 
of  returning  power  in  the  muscles  after  a  period  of  three  months, 
particularly  in  those  cases  in  which  the  muscles  of  the  forearm  are 
involved,  an  exploratory  operation  is  indicated. 

Kennedy^  has  operated  on  a  number  of  cases  for  this  purpose,  in 
one  instance  as  early  as  two  months  after  birth,  and  a  large  number 
of  cases  in  early  infancy  have  been  operated  on  recently  by  William 
Sharpe. 

Kennedy's  method  as  modified  slightly  by  A.  S.  Taylor^  is  described 
by  the  latter  as  follows: 

"The  patient  is  anesthetized  and  brought  to  the  table  with  the 
field  prepared  for  operation.  A  firm  cushion  is  placed  beneath  the 
shoulders,  the  neck  is  moderately  extended  and  the  face  turned  to 
the  sound  side.  The  incision  passes  from  the  base  of  the  sterno- 
mastoid  muscle  backward  and  slightly  upward,  following  the  fold 
of  the  skin  to  the  anterior  border  of  the  trapezius.  After  the  skin, 
platysma  and  deep  fascia  are  divided,  the  omohyoid  muscle  is  exposed 
near  the  clavicle,  and  lying  beneath  it  are  the  suprascapular  vessels. 
These  structures  may  be  retracted  downward,  or,  if  the  case  requires 
the  extra  room,  the  omohyoid  may  be  divided,  and  then  the  vessels 
cut  between  double  ligatures.  The  transversalis  colli  vessels  are 
seen  a  little  below  the  middle  of  the  wound  and  are  divided  between 
double  ligatures. 

"The  dissection  is  rapidly  carried  through  the  fat  layer  to  the  deep 
cervical  fascia  covering  the  brachial  plexus,  which  fascia  is  usually 
thickened  and  adherent  to  the  damaged  nerve  roots.  This  fascia 
is  divided  in  the  line  of  the  original  incision  and  is  dissected  away 
for  the  free  exposure  of  the  nerves  (Fig.  377) .  The  damaged  nerves 
are  usually  noticeably  thickened  and  of  greater  density  than  normal 
nerves.  The  extent  and  distribution  of  the  paralysis,  determined 
before  operation,  gives  the  clue  as  to  which  nerves  are  at  fault. 
Usually  the  junction  of  the  fifth  and  sixth  roots  is  the  site  of  maxi- 

'  Am.  Jour.  Orth.  Surg.,  August  5,  1916. 

2  British  Med.  Jour.,  1903,  p.  298. 

^A.  S.  Taylor:    Jour.  Am.  Med.  Assn.,  xlviii,  No.  2. 


496 


DEFORMITIES  OF   THE   UPPER  EXTREMITY 


mum  damage.  The  thickened  indurated  areas  are  determined  by 
palpation  and  are  excised  b}"  means  of  a  sharp  scalpel.  Scissors 
should  never  be  used  for  this  ■v^•ork. 

"The  nerve  ends  are  brought  into  apposition  by  lateral  sutures  of 
fine  silk  involving  the  nerve  sheaths  only,  while  the  neck  and 
shoulder  are  approximated  to  prevent  tension  on  the  sutures.  Car- 
gile  membrane  is  wrapped  about  the  anastomosis  to  prevent  connec- 
tive-tissue ingrowth.  The  omohyoid  muscle,  if  divided,  is  sutured. 
The  wound  is  closed  with  silk.  A  firm  sterile  dressing  is  applied, 
and  a  bandage  is  applied  to  approximate  head  and  shoulder  so 


Fig.  377. — Operation  for  relief  of  brachial  paralysis.  (Taylor.)  A,  scalenus 
anticus  muscles.  B,  phrenic  nerve.  C,  internal  jugular  vein.  D,  transversalis  colli 
artery.  E,  seventh  root.  F,  omohyoid  muscle.  G,  fifth  root.  H,  scalenus  medius 
muscle.  I,  sixth  root.  /,  transversalis  colli  artery.  K,  suprascapular  nerve.  L, 
external  anterior  thoracic  nerve.  M,  cla^■icle.  N,  nerve  to  subclavius.  The  incision 
now  follows  the  fold  of  the  neck  across  the  posterior  triangle  as  described  in  the  text. 


as  to  prevent  tension  on  the  nerve  sutures.  This  position  must  be 
maintained  for  at  least  three  weeks.  The  most  feasible  method  of 
accomplishing  this  result  is  a  plaster-of-Paris  support  placed  on  the 
child  and  allowed  to  harden  in  the  proper  position  before  operation. 
It  is  then  trimmed  and  removed.  ^Yhen  the  nerve  suturing  is  fin- 
ished the  splint  is  slipped  on,  the  wound  is  then  closed,  the  dressings 
applied,  and  the  child  put  to  bed  without  danger  of  pulling  the  nerve 
ends  apart. 

"It  will  be  noticed  (Fig.  377)  that  the  tissues  to  be  excised  lie 
in  close  proximity  to  the  phrenic  nerve  and  internal  jugular  vein, 


RECURRENT  DISLOCATION  OF   THE  SHOULDER         497 

and  to  the  junction  of  the  cervical  sympathetic  communications 
with  the  spinal  nerve  roots.  The  suprascapular  nerve  comes 
off  from  the  junction  of  the  fifth  and  sixth  cervical  nerve  roots, 
which  as  already  stated,  is  usually  the  site  of  maximum  damage. 
This  nerve  is  very  small  in  children,  but  it  should  be  sutured  with 
the  greatest  care,  since  it  innervates  the  external  rotators  of  the 
humerus,  the  paralysis  of  which  permits  the  posterior  dislocation  of 
the  shoulder  often  seen  in  the  older  cases." 

If  the  deformity  is  of  long  standing,  operations  on  the  injured 
nerves  pf  soiyewhat  doubtful  utility  at  best  can  have  no  influence 
on  the  disabifity  unless  distortions  and  contractions  have  been  pre- 
viously overcome  in  the  manner  already  described. 

RECURRENT  DISLOCATION  OF  THE  SHOULDER. 

Recurrent  dislocation  of  the  shoulder  is  in  most  instances  a 
sequel  of  traumatic  dislocation.  The  cause  of  the  instability  is 
usually  laxity  of  the  capsular  ligament  and  weakness  of  the  support- 
ing muscles,  the  result,  it  may  be,  of  too  early  use  of  the  arm 
after  the  accident.  In  rare  instances  greater  derangement  of  the 
joint  caused  by  fracture  of  one  or  other  of  the  articulating  sur- 
faces, rupture  or  displacement  of  ligaments  or  muscles,  or  permanent 
paralysis  of  the  deltoid  muscle  may  be  present. 

The  displacement,  which  may  be  partial  or  complete,  recurs  at 
intervals  and  is  a  very  serious  disability. 

Treatment. — If  the  patient  is  seen  immediately  after  a  displace- 
ment and  if  the  dislocation  has  recurred  but  a  few  times  and  at  long 
intervals,  it  may  be  inferred  that  the  disability  is  the  result  of  simple 
laxity  of  the  capsule  and  of  muscular  weakness.  In  such  cases  a 
period  of  fixation  followed  by  massage  and  exercise  of  the  atrophied 
muscles  may  result  in  cure.  The  patient  should  be  carefully  ques- 
tioned as  to  the  particular  movements  of  the  arm  that  are  likely 
to  cause  the  displacement,  which  is,  as  a  rule,  forward  beneath  the 
coracoid  process.  Most  often  elevation  and  abduction  seem  to  be 
the  predisposing  movements  that  should  be  restrained.  A  simple 
and  often  an  effective  means  of  treatment  is  the  application  of  a 
shoulder-cap  of  canvas  that  fits  closely  about  the  shoulder  and  upper 
arm.  This  is  held  in  place  by  bands  crossing  the  body  and  buckled 
beneath  th(;  other  arm;  from  the  lower  border  of  the  cap  one  or 
more  bands  pass  downward  and  are  attached  with  the  braces  to  the 
trousers,  so  that  elevation  of  the  arm  is  restrained,  before  the  point 
of  instability  is  reached. 

Operative. — ^If  these  milder  measures  are  ineffective,  an  operation 
to  reduce  the  size  of  the  lax  capsule  may  be  performed.  The  arm 
being  slightly  abducted,  an  incision  is  made  from  the  coracoid  pro- 
cess downward  and  outward  along  the  line  of  the  cephalic  vein  to  a 
point  below  the  upper  border  of  the  tendinous  insertion  of  the  pec- 
32 


498  DEFORMITIES  OF   THE   UPPER  EXTREMITY 

toralis  major.  The  deltoid  and  the  pectoralis  major  are  separated, 
exposmg  m  the  upper  border  of  the  ^'ound  the  coracobrachialis, 
and  m  the  lower  angle  the  upper  part  of  the  insertion  of  the  pec- 
toralis major  muscles.  The  upper  three-fourths  of  this  insertion  is 
divided  in  order  to  expose  the  head  and  neck  of  the  bone.  The 
humerus  is  then  rotated  outward  and  a  portion  of  the  insertion  of 
the  subscapularis  muscle,  stretched  over  the  head  of  the  humerus, 
is  divided.  The  capsule  is  thus  laid  bare.  It  is  incised  and  over- 
lapped to  the  required  degree. 

T.  T.  Thomas^,  the  arm  being  abducted,  makes  an  incision  in  the 
axilla  about  five  inches  in  length  along  the  coracobrachialis  muscle. 
This  muscle  with  the  biceps  and  pectoralis  major  are  retracted  out- 
ward, the  axillary  vessels  and  nerves  inward,  about  half  the  width 
of  the  subscapularis  being  divided  on  a  director,  the  capsule  is 
exposed,  divided,  overlapped  by  drawing  the  upper  over  the  lower 
margin  to  the  desired  degree,  and  sutured  with  Xo.  3  chromicized 
gut;  the  subscapularis  is  reunited  and  the  wound  closed. 

CONGENITAL  DEFORMITIES  OF  THE  ELBOW. 

Congenital  displacement  of  the  ulna  is  one  of  the  rarest  of  deformi- 
ties. The  displacement  is  usually  incomplete,  and  it  is  associated 
with  laxity  of  the  ligaments. 

Congenital  displacement  of  the  radius  is  much  more  common, 
53  cases  having  been  reported.- 

In  many  instances  the  head  of  the  radius  is  displaced  backward; 
thus  the  forearm  is  pronated  and  extension  is  usually  limited. 
Removal  of  the  head  of  the  radius  and  forcible  correction  is  usually 
indicated. 

CONGENITAL  PRONATION  OF  THE  FOREARM. 

This  deformity  is  usually  bilateral  and  it  is  often  an  accompani- 
ment of  fusion  of  the  upper  extremities  of  the  radius  and  ulna, 
usually  to  the  extent  of  about  two  inches  (Fig.  378). 

Treatment. — The  bones  may  be  cut  apart  with  a  chisel  and 
separated  by  the  insertion  of  a  flap  of  fibromuscular  or  transplanted 
fatty  tissue.  If  the  head  of  the  radius  is  fixed  it  may  be  removed 
or  the  bone  may  be  divided  at  its  neck.  The  attitude  may  be 
improved  by  operative  treatment  and  in  favorable  cases  some 
motion  may  be  regained. 

CUBITUS  VALGUS— CUBITUS  VARUS. 

Cubitus  valgus,  in  which  the  forearm  is  abducted  at  the  elbow 
and  cubitus  varus,  in  which  it  is  inclined  in  the  other  direction, 

1  Jour.  Am.  Med.  Assn.,  March  12,  1910. 

2  Blodgett:  Am.  Jour.  Orthop.  Surg.,  January,   1906. 


CUBITUS   VALGUS— CUBITUS   VARUS 


499 


are  occasionally  seen  as  congenital  deformities.  They  are,  in  most 
instances,  associated  with  laxity  of  the  ligaments. 

Similar  deformities  are  not  uncommon  during  the  progressive 
stage  of  rhachitis,  but  they  usually  disappear  after  the  erect  attitude 
is  assumed. 

The  supinated  forearm  forms  an  angle  with  the  upper  arm, 
opening  outward  when  the  limb  is  extended  at  about  173  degrees 
in  males  and  167  degrees  in  females.^    This  is  called  the  "carrying" 


Fig.  378. — Bilateral  congenital  pronation  of  the  forearms. 

angle,  because  the  hand  is  held  at  some  distance  from  the  body 
while  the  arm  is  in  contact  with  the  trunk.  The  angle  is  caused  by 
the  obliquity  of  the  ulnohumeral  joint  and  it  is  not  apparent  when 
the  forearm  is  pronated.  What  may  be  called  normal  cubitus  val- 
gus is  common  among  women,  and  in  certain  instances  it  may  be 
exaggerated  to  deformity.  Acquired  cubitus  varus  is  usually  the 
result  of  direct  injury.  Both  deformities  may  be  treated  by  oste- 
otomy of  the  humerus  just  above  the  articulation  after  the  method 

1  Potter:    Jour.    Anat.    andlPhys.,    xxix,    488.     Hubscher:    Deutsch.    Ztschr.    f. 
Chir.,  liii. 


500 


DEFORMITIES  OF   THE   UPPER  EXTREMITY 


used  to  correct  similar  deformity  at  the  knee.  If  in  addition  to  the 
lateral  deformity  motion  is  restricted  by  displaced  fragments  of  bone 
or  by  exuberant  callus  it  is  advisable  to  open  the  joint  for  the 
correction  of  lateral  deformity  if  the  patient  is  to  walk  about,  the 
arm  should  be  fixed  in  full  extension  and  supination  by  a  shoulder 
spica  plaster  bandage,  the  limb  being  elevated.  Thus  the  danger 
of  swelling  and  constriction,  almost  inevitable  if  the  limb  is  pendant, 
may  be  avoided.     (Fig.  379.) 


'  Fig.  379. — The  shoulder  spica.  This  support  is  used  after  correction  of  lateral 
deformity  at  the  elbow  and  in  the  treatment  of  fractures  with  lateral  distortion. 
The  same  support  is  used  in  the  treatment  of  epiphyseal  fracture  at  the  shoulder, 
the  fragments  being  held  in  apposition  after  reduction  by  fixing  the  arm  in  a  nearly 
perpendicular  attitude  with  forward  inclination.  The  arm  may  be  fixed  in  any  angle 
in  relation  to  the  trunk,  the  forearm  flexed,  pronated  or  supinated,  according  to  the 
indications.     Whitman,  Annals  of  Surgery,   May,   190S. 


SUBLUXATION  OF  THE  WRIST. 

A  peculiar  displacement  of  the  hand  forward  and  usually  toward 
the  radial  side,  first  noted  by  Malgaigne  and  described  by  Made- 
lung^  as  "spontaneous  subluxation,"  is  sometimes  seen  in  young 

1  Arch.  f.  klin.  Chir.,  xxiii, 


CONGENITAL  DEFORMITIES  AT  THE  WRIST  501 

subjects.  In  these  cases  the  lower  extremity  of  the  uhia  is  displaced 
toward  the  dorsum  of  the  hand ;  there  is  abnormal  separation  of  the 
bones  of  the  forearm  from  one  another  at  the  wrist,  and  usually  the 
lower  extremity  of  the  radius  is  bent  forward.  As  a  consequence 
the  wrist  is  enlarged,  the  ligaments  are  relaxed,  and  dorsal  flexion 
of  the  hand  is  restricted  and  if  the  deformity  is  extreme,  pronation 
and  supination  also.  Destot  suggests  the  term  curved  radius  as 
more  properly  descriptive  of  the  affection,  as  there  is  no  subluxation 
except  in  extreme  cases.  Lenormant^  has  collected  47  cases  from 
literatyre.  Twenty  three  were  bilateral,  24  were  unilateral  (12 
of  the  left,  9  of  the  right,  3  unspecified).  The  symptoms,  aside 
from  the  deformity  and  limitation  of  motion,  are  weakness  and 
sensations  of  discomfort  about  the  dorsum  of  the  wrist. 


Fig.  380. — -"Spontaneous  subluxation  of  the  wrist." 

Etiology. — The  deformity  most  often  develops  in  later  childhood 
and  adolescence.  The  predisposing  causes  of  the  affection  are, 
apparently,  relaxation  of  the  ligaments,  and,  probably,  slight  pre- 
existing rhachitic  deformity  of  the  same  character.  The  exciting 
causes  are  occupation  and  injury. 

Treatment. — The  treatment  is  rest,  massage,  forcible  manipu- 
lation in  the  direction  of  extension,  and  a  support  of  leather  or  other 
material  to  hold  the  hand  in  the  extended  position.  In  well-marked 
cases  the  deformity  of  the  radius  should  be  corrected  by  osteotomy. 
Deformities  of  the  hand  due  to  overgrowth  of  one  or  other  of  the 
bones  of  the  forearm  or  to  loss  of  growth  caused  by  disease  or  opera- 
tive treatment  are  occasionally  seen.  Radical  operations  in  early 
life  which  involve  removal  of  growing  bone  should  always  be  avoided. 

CONGENITAL  DEFORMITIES  AT  THE  WRIST. 

Simple  congenital  dislocation  at  the  wrist  is  extremely  rare. 
Displacement  of  the  wrist  and  hand  is  usually  associated  with 
defective  development  of  the  bones  of  the  arm,  and  the  deforrhity 
is  usually  classed  as  club-hand. 

1  Rev.  d'Orthop.,  January,  1907, 


502 


DEFORMITIES  OF   THE   UPPER  EXTREMITY 


CLUB-HAND. 

Congenital  distortions  of  the  hand  may  be  divided  into  four 
primary  varieties,  iaccording  to  the  direction  in  which  the  hand  is 
turned,  viz.: 

1.  Forward  or  palmar. 

2.  Backward  or  dorsal. 

3.  Lateral  to  the  radial  side — radial. 

4.  Lateral  to  the  ulnar  side — ulnar. 

Lateral  and  anteroposterior  distortions  occur  also  in  combination. 


Fig.  381.— Club-hands  and  club-feet. 


Etiology. — There  are  two  distinct  varieties  of  club-hand: 

1.  In  which  there  is  simple  distortion  caused  apparently  by 
abnormal  restraint  and  pressure  in  idem.  Li  certain  cases  of  this 
class  there  may  be  limited  motion  at  both  the  shoulder  and  elbow- 
joints  and  defective  muscular  development,  apparently  dependent 
upon  long-continued  fixation. 

2.  In  which  the  deformity  is  associated  with  defective  develop- 
ment of  the  radius  or  ulna  and  often  with  congenital  abnormalities 
of  other  parts. 

In  the  palmar  and  dorsal  distortions  the  bones  of  the  arm  are 
usually  normal.  The  lateral  deviations  of  the  hand  are  often  com- 
plicated by  defective  formation  of  the  radius  or  ulna,  and  as  in  talipes 
due  to  absence  of  the  tibia  or  fibula  the  hand  may  be  malformed  also. 

Deficient  formation  of  the  radius  with  corresponding  distortion 


CLUB-HAND 


503 


is  the  most  common.  Of  this  114  cases  are  recorded.  In  56  cases 
it  was  stated  that  the  deformity  was  unilateral,  in  46  bilateral.  In 
44  cases  the  radius  was  absent;  in  12  cases  a  part  was  present;  60 
per  cent,  of  the  patients  were  males.^ 

The  most  important  form  of  club-hand  is,  then,  that  due  to 
absence  or  to  defective  formation  of  the  radius.  As  in  talipes 
valgus  due  to  absence  of  the  fibula,  the  tibia  is  short  and  often  bent 
sharply  forward,  so  in  this  form  of  club-hand  the  ulna  is  usually 
short  and  bent  inward.  The  hand  may  be  perfect  in  formation, 
but,  as  a  rule,  the  thumb  is  absent  or  rudimentary,  and  other  adjoin- 
ing bones,  together  with  the  corresponding  ligaments  and  muscles, 
may  be  absent  also^  (Fig-  382). 


Fig.  382. — Congenital  absence  of  radius  and  the  bones  of  the  thumb.   (Weigel.) 

The  hand  occupies  practically  a  right-angled  relation  to  the  ulna, 
and  as  this  bone  is  usually  bent  inward  as  well,  the  direction  of  the 
hand  is  often  reversed  and  is  parallel  to  the  forearm.  As  a  rule 
the  hand  is  also  somewhat  bent  forward,  so  that  the  deformity  might 
be  described  as  radiopalmar  (Fig.  383). 

Treatment. — In  those  forms  of  club-hand  in  which  the  structure 
is  normal  the  deformity  may  be  overcome,  as  a  rule,  by  manipula- 
tion, and  support  by  the  plaster  bandage  or  otherwise,  as  described 
in  the  treatment  of  talipes.  Massage  and  muscle  training  are 
required  in  the  after-treatment.     If  the  deformity  is  complicated 


1  Antonelli:  Ztschr.  f.  orthop.  Chir.,  1905,  xiv. 

2  Stoffel  u.  Stempel:  Ztschr.  f.  orthop.  Chir.,  1909,  xxiii,  Heft  1  und  2. 


504 


DEFORMITIES  OF  THE   UPPER  EXTREMITY 


by  defective  muscular  development  and  limited  joint  motion  mas- 
sage and  passive  manipulation  may  be  required  for  years.  Com- 
plete recovery  is  unusual. 

In  slighter  cases  of  radial  club-hand,  due  to  defective  develop- 
ment, it  may  be  possible  by  manipulation  and  tenotomy  to  replace 

the  hand  in  its  normal  position, 
but  this  is  unusual.  After  division 
of  the  contracted  tissues,  Sayre^ 
removed  a  portion  of  the  carpus 
and  implanted  the  head  of  the 
ulna  at  the  point  of  resection. 
]\IcCurdy-  sawed  tlirough  the  ulna, 
leaving  the  extremity  in  relation 
to  the  carpus  and  sutured  the 
proximal  fragment  and  the  semi- 
lunar bone  to  one  another.  Thom- 
son^ replaced  the  hand  by  sub- 
cutaneous tenotomy  and  by  the 
removal  of  a  cuniform  section  of 
bone  from  the  lower  end  of  the  ulna. 
The  operation  of  splitting  the 
ulna  into  an  ulna  and  radial  portion 
and  implanting  the  carpus  between 
the  two  has  been  performed  by 
Bardenlieuer.^  The  immediate  ef- 
fect of  the  various  operative  pro- 
cedures was  favorable,  but  no 
final  results  have  been  reported. 

In  any  event  some  form  of  ap- 
paratus must  be  used  during  child- 
hood at  least,  to  support  the  hand, 
whether  the  operation  has  been 
successful  or  not.  It  is  therefore 
better  to  defer  radical  treatment. 
At  best  the  arm  will  be  short  and 
Fig. 383 -Congenital club-hands'    ^j     defective  hand  will  be  weak  as 

showing    the    short   and    deformed  i       •  i      i 

forearms,  also  bow-legs.     (Gibney.)       Compared  With  the  normal. 


CONTRACTIONS  AND  DISTORTIONS  OF  THE  FINGERS. 

Congenital  Contraction  of  the  Fingers. — The  most  common  form 
of  congenital  contraction  and  one  that  is  sometimes  hereditary  is 
that  of  the  little  finger  (hammer-finger)  of  one  or  both  hands.  This 
is  semiflexed  and  extension  is  checked  by  what  appears  to  be  a  con- 
genital shortening  of  all  the  soft  parts  on  the  flexor  side.  In  other 
instances  several  fingers  may  be  similarly  affected. 


1  Tr.  Am.  Orthop.  Assn.,  \i.  -  Ibid.,  ^'^ii. 

4  Verhand.  der  deutsch.  Gesells.  f.  Chir.,  1894,  23  Kong 


^  Ibid.,  ix. 


CONTRACTIONS  AND  DISTORTIONS  OF  FINGERS        505 

Treatment. — If  treatment  by  manipulation  and  splinting  is  begmi 
early  the  deformity  may  be  overcome  by  lengthening  the  contracted 
tissue.  In  later  life  the  prospect  of  perfect  cure  by  any  method  of 
treatment  is  slight,  because  of  the  strong  tendency  to  recontraction 
after  the  finger  has  been  straightened. 

Webbed  Fingers. — In  the  most  common  form  of  this  deformity 
two  or  more  fingers  are  joined  by  skin  and  fibrous  tissue  to  the  first 
phalangeal  joints,  but  sometimes  throughout  the  entire  length  of 
the  fingers. 

In  oiher  instances  the  web  may  be  thicker,  containing  muscular 
fibres  from  the  apposed  parts,  and,  occasionally,  the  bones  of  the 
two  fingers  may  be  joined  to  one  another,  even  to  the  finger-nails. 

Etiology. — The  cause  of  the  deformity  is  arrest  of  development 
before  the  fingers  have  been  separated  from  one  another;  thus  the 
thumb,  which  is  differentiated  from  the  other  parts  of  the  hand  as 
early  as  the  seventy-fifth  day  of  intra-uterine  life,  is  rarely  involved, 
as  compared  with  the  fingers,  which  are  separated  from  one  another 
at  a  later  period. 

Treatment. — In  all  but  the  extreme  grades  of  deformity  the 
fingers  may  be  separated  from  one  another,  operative  treatment 
being  conducted  according  to  the  rules  of  plastic  surgery. 

Congenital  Displacements  of  the  Phalanges  and  Distortions  of 
the  Fingers. — These  deformities  are  not  particularly  uncommon. 
They  should  be  treated  by  manipulation  and  by  splinting  at  as 
early  a  period  as  is  practicable.  Other  congenital  deformities  and 
malformations  of  the  hand  do  not  call  for  extended  comment. 

Trigger-finger. — Synonyms. — Jerking  finger,  snapping  finger.  ^ 

This  aftection  was  first  described  by  Nelaton  under  the  title 
"Doigt  a  Ressort."  On  extending  the  closed  hand  one  finger 
remains  flexed.  If  the  flexion  is  overcome  by  greater  muscular 
effort  or  by  passive  force  the  finger  flies  back  to  complete  extension 
with  a  sudden  snap  or  jerk;  hence  the  name.  In  well-marked  cases 
the  same  difficulty  and  the  subsequent  snap  occurs  on  flexing  the 
finger.  The  middle  and  ring  fingers  are  more  often  affected,  but 
sometimes  the  thumb  or  the  other  fingers  may  be  involved. 

The  patient  usually  complains  somewhat  of  stiffness  and  pain 
in  the  finger,  but  the  interference  with  its  function  is  the  principal 
symptom. 

Etiology. — The  cause  of  the  disability  is  interference  with  the 
motion  of  the  tendon  in  its  fibrous  sheath,  either  because  of  a  reduc- 
tion of  its  calibre  due  to  injury  or  inflammation,  or  to  an  enlarge- 
ment or  irregularity  of  the  tendon  itself.  In  most  instances  the 
obstruction  appears  to  be  in  the  neighborhood  of  the  metatarso- 
phalangeal joint.^ 

The  duration  of  the  affection  is  indefinite. 

1  Marches:  Deutsch.  Ztschr.  f.  Chir.,  Ixxix,  364. 


506  DEFORMITIES  OF   THE   UPPER  EXTREMITY 

Treatment. — If  the  obstruction  appears  to  be  of  inflammatory  or 
traumatic  origin  it  may  be  treated  by  splinting  and  later  by  mas- 
sage. In  confirmed  cases  the  sheath  should  be  opened  to  remove 
the  obstruction.  As  a  rule  it  is  only  necessary  to  split  the  sheath  to 
assure  relief. 

The  bibliography  is  large;  the  more  recent  articles  are  those  of 
Poulsen/  who  reports  64  cases,  and  Abbe.- 

MaUet-finger. — Synonym. — Drop-finger. 

This  is  caused  usually  by  a  blow  upon  the  terminal  phalanx, 
which  ruptures  or  weakens  the  attaclmient  of  the  extensor  tendon 
at  the  base  of  the  phalanx  so  that  it  is  habitually  flexed  sometimes 
nearly  to  a  right  angle. 

The  treatment  must  be  by  incision  and  reattachment  of  the 
tendon  to  the  periosteum. 

"Baseball-finger"  is  the  reverse  displacement  of  the  terminal 
phalanx,  which  is  dislocated  backward,  forming  a  bayonet-like 
deformity.  There  is  often,  in  addition,  mjury  of  the  base  of  the 
phalanx  that  causes  subsequent  irregular  hypertrophy. 

If  reposition  is  impossible  open  incision  may  be  employed  to  cor- 
rect the  deformity. 

Dupuytren's  Contraction. — Dupuytren's  contraction  is  a  deform- 
ity of  the  hand  caused  by  contraction  of  a  part  of  the  palmar  fascia 
and  of  its  prolongations  to  one  or  more  of  the  fingers.  The  fingers 
are  flexed  as  a  consequence  to  a  greater  or  less  degree,  and  in 
advanced  cases  they  may  be  drawn  to  close  contact  with  the  palm. 
The  ring  finger  is  most  often  primarily  aft'ected,  but,  as  a  rule,  two 
or  more  fingers  are  somewhat  involved  in  the  contraction. 

In  a  large  proportion  of  the  cases  both  hands  are  aft'ected,  but  not 
as  a  rule  simultaneously,  the  contraction  begimiing  in  the  second 
hand  several  years  after  the  deformity  in  the  first. 

Etiology. — ^The  etiology  is  uncertain. 

The  contraction  is  much  more  common  in  men  than  in  women, 
and  it  is  practically  confined  to  middle  and  later  life.  It  is  claimed 
that  the  deformity  is  more  common  among  those  who  are  subject 
to  gout  or  rhemnatism.  It  appears,  also,  to  be  an  hereditary  affec- 
tion in  certain  instances.  Injury  or  irritation  of  the  palmar  tissues, 
incident  to  certain  occupations,  would  seem  to  explain  the  dispro- 
portionate liability  of  the  sexes  to  the  aft'ection. 

Pathology .^ — The  characteristics  of  the  deformity  are  explamed 
by  the  anatomy  of  the  palmar  fascia.  This  consists  of  a  strong 
central  portion,  and  two  thinner  lateral  parts  that  cover  the  muscles 
of  the  thumb  and  little  finger.  It  is  made  up  of  longitudinal  fibres 
continuous  with  the  tendon  of  the  palmaris  longus,  and  the  annular 
ligaments.  It  divides  into  four  processes  that  are  attached  to  the 
digital  sheaths,  to  the  integument  at  the  clefts  of  the  fingers,  and  to 

1  Arch.  f.  kUn.  Chir.,  xciv,  Heft  3. 

2  New  York  Med.  Rec,  March  7,  1914. 


ISCHEMIC  PARALYSIS  AND  CONTRACTION  507 

the  superficial  transverse  ligament.  Prolongations  of  the  fascia 
pass  along  the  lateral  aspect  of  the  fingers  and  are  attached  to 
the  periosteum  and  to  the  tendon  sheaths  of  the  first  and  second 
phalanges. 

The  cause  of  the  contraction  appears  to  be  a  chronic  plastic 
inflammation  of  a  part  of  the  fascia,  which  becomes  hypertrophied 
and  finally  contracts,  drawing  the  finger  toward  the  palm  in  the 
manner  described.  The  affection  progresses,  as  a  rule,  very  slowly 
but  in  rare  instances  the  onset  is  more  acute,  attended  by  thickening 
and  sensitiveness  of  the  fascia. 

Symptoms.  —  The  first  symptom  is  usually  the  deformity;  the 
patient  finds  it  impossible  to  completely  extend  one  or  more  of  the 
fingers;  the  tissues  about  the  base  of  the  finger  seem  stiff,  and  when 
it  is  forcibly  extended  a  hard,  elevated  cord  may  be  felt  extending 
from  about  the  centre  of  the  palm  to  the  second  phalanx,  most 
prominent  at  the  metacarpophalangeal  articulation. 

To  this  the  skin  is  adherent,  and  as  the  contraction  increases  it 
is  thrown  into  elevated  ridges.  Later  other  bands  appear  if  the 
contraction  afi^ects,  as  it  usually  does,  other  portions  of  the  fascia. 
In  many  instances  do  pain  is  experienced  unless  the  contracted 
fascia  is  forcibly  stretched  or  is  passed  upon.  In  other  cases  com- 
plaint is  made  of  neuralgic  pain  in  the  hand  and  even  in  the  arm 
and  back.  Occasionally  the  first  symptom  to  attract  attention 
may  be  a  sensitive  nodule  in  the  skin  at  the  base  of  the  finger. 

The  contraction  usually  increases  slowly  until  the  finger  that  is 
most  affected  is  drawn  to  the  palm. 

Treatment. — When  the  contraction  interferes  with  the  function 
of  the  hand  operation  is  indicated  by  removal  of  the  contracted 
fascia.  This  may  be  best  accomplished  by  long  incisions  over  the 
prominent  bands.  The  skin  is  carefully  separated  from  the  adher- 
ent fascia  which,  with  its  lateral  prolongations  to  the  joints,  is  dis- 
sected from  the  underlying  parts. 

In  severe  cases  multiple  incisions  are  required.  The  wounds  are 
sutured  and  the  hand  and  fingers  are  supported  on  a  splint  in  a 
slightly  flexed  position  in  order  that  the  circulation  may  not  be 
restricted.     Later  massage  and  stretching  will  complete  the  cure. 

ISCHEMIC  PARALYSIS  AND  CONTRACTION.^ 

Paralysis  and  contraction  may  follow  prolonged  constriction. 
This  is  most  often  seen  in  the  forearm  and  hand  in  young  subjects, 
as  a  result  of  treatment  for  fracture  about  the  elbow. 

Symptoms. — The  prodromal  symptoms  are  pain,  swelling,  dis- 
coloration, loss  of  sensation  and  finally  of  motion.  It  is  estimated 
that  moderate  constriction  for  six  hours  may  cause  paralysis  which, 

1  Volkmann:  Centralbl.  f.  Chir.,  1881,  viii,  801. 


508  DEFORMITIES  OF  THE   UPPER  EXTREMITY 

in  cases  of  the  milder  type,  is  limited  to  the  extensor  group.  If  the 
hand  is  not  supported  contraction  follows.  In  characteristic  cases 
the  hand  is  flexed  on  the  forearm,  and  the  fingers  at  the  interphalan- 
geal  joints  are  contracted  to  a  right-angular  attitude.  Extension 
is  restrained  by  a  resistant  shortening  of  the  tissues  on  the  flexor 
aspect  of  the  arm  caused  by  fibrous  degeneration  of  the  muscles 
the  result  of  traumatic  myositis.  The  aftected  part  is  atrophied  and 
cold.  ^Sensation  in  the  fingers  is  often  dimmished  or  lost  m  about 
60  of  the  cases,  due  probably  to  secondary  involvement  and  con- 
striction of  the  nerves. 

Treatment. — Prevention. — The  possibility  of  this  complication 
should  be  borne  in  mind  when  treating  fractures  or  correcting 
deformity  at  the  elbow.  The  hand  should  be  examined  frequently 
and  the  patient  should  be  instructed  to  move  the  fingers  from  time 
to  time.  Pain  and  swelling  indicate  the  necessity  for  complete 
relief  of  constriction.  Neglect  of  this  precaution  is  indicated  by  the 
fact  that  in  37  of  107  cases  there  was  sloughing  of  the  tissues  on  the 
palmar  side  of  the  arm.  If  paralysis  is  present  the  hand  should  be  at 
once  supported  in  hyperextension  to  prevent  contraction.  In  most 
cases,  however,  confirmed  deformity  is  already  present  when  the 
patient  is  brought  for  treatment. 

Corrective. — The  most  efficient  method  of  treatment  is  that  of 
gradual  correction  advocated  by  Jones,  of  Liverpool.  This  is  con- 
ducted methodically  along  the  line  of  least  resistance.  It  may  be 
noted  that  although  the  fingers  are  rigidly  contracted  at  the  inter- 
phalangeal  joints  where  the  hand  is  extended,  the  contraction  is 
lessened  if  the  wTist  is  flexed.  One  begins,  therefore,  by  flexing  the 
hand  on  the  forearm  to  relax  the  tension.  Straight  splints  are  then 
applied  to  the  flexor  side  of  the  fingers  and  from  day  to  day  more 
pressure  is  applied  until  each  finger  is  straightened.  When  this  is 
accomplished  a  palmar  splint  of  metal  bent  to  fit  the  deformity  is 
applied  to  the  forearm  and  hand.  This  is  gradually  straightened 
to  extend  the  splinted  fingers  on  the  hand.  When  these  are  hyper- 
extended,  one  begins  in  the  same  manner  to  correct  the  fiexion  at 
the  WTist  until  in  successful  cases  after  weeks  or  months  hyper- 
extension at  all  the  deformed  joints  has  been  accomplished.  During 
the  treatment  the  power  in  the  extensor  group  increases  and  sensa- 
tion improves.  ^Massage,  manipulation  exercises  and  the  like  for 
an  mdefinite  time  are  of  course  essential  supplements  to  the  correc- 
tion of  deformity. 

Operation. — If  the  contraction  resists  mechanical  correction  a  long 
incision  may  be  made  m  the  contracted  tissues  in  the  forearm  from 
which  the  adherent  fascia  is  dissected.  The  contracted  tendons  are 
then  lengthened,  preferably  at  the  jmiction  with  the  muscular  sub- 
stance. Shortening  of  the  bones  in  adaptation  to  the  contraction 
seems  inadvisable. 


CHAPTER   XIV. 

CONGENITAL  AND  ACQUIRED  AFFECTIONS  LEADING 
TO  GENERAL  DISTORTIONS. 
* 

RHACHITIS. 

Synonym. — Rickets . 

Rhachitis  is  a  constitutional  disease  of  infancy  caused  by  defective 
nutrition,  of  which  the  most  marked  effect  is  distortion  of  the  bones. 

Etiology. — The  predisposing  cause  is  constitutional  weakness. 
This  may  be  inherited  or  it  may  be  the  direct  effect  of  illness,  but 
most  often  it  is  the  result  of  improper  hygienic  surroundings,  par- 
ticularly lack  of  sunlight,  damp  rooms  and  overcrowding.  The 
direct  cause  of  the  di,  ease  is  defective  assimilation.  In  most 
instances  this  is  due  to  the  substitution  of  artificial  food  for  the 
mother's  milk,  in  others  to  improper  diet  after  the  infant  is  weaned 
in  rare  cases  it  may  be  the  result  of  prolonged  lactation,  or  it  may  be 
caused  by  the  defective  quality  of  the  mother's  milk.  The  disease, 
therefore,  begins  usually  between  the  ages  of  six  and  eighteen 
months,  although  it  is  by  no  means  confined  to  these  limits. 
According  to  Baginsky  the  age  of  onset  in  623  cases  was  as  follows: 

Male.  Female.  Total. 

3    to    6    months 35  8  43 

6    to  12    months 101  72  173 

1  to    li  years 115  105  220 

li  to    2    years 64  49  113 

2  to    2i  years 18  24  42 

2|  to    3    years 9  12  21 

3  to    4    years 2  5  7 

4  to  13    years 4  0  4 

348  275  623 

In  most  instances  improper  surroundings  and  improper  nourish- 
ment are  combined  in  the  causation  of  the  disease;  thus  rhachitis 
is  relatively  common  in  large  cities.  In  New  York  the  most  extreme 
cases  are  observed  among  the  Italian  and  the  colored  children. 
The  former  are  usually  nursed,  but  are  improperly  fed  after  weaning 
while  the  latter,  if  nursed  at  all,  are  usually  allowed  a  mixed  diet 
even  during  the  early  months  of  life. 

Pathology. — The  manifestations  of  a  disease  induced  by  impaired 
nutrition  are,  of  course,  general  in  character.  In  rhachitis  there  is 
a  mild  degree  of  anemia,  and  general  weakness  and  relaxation  of  the 
voluntary  and  involuntary  muscles.     As  a  result  the  circulation  is 


510  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

impaired  and  the  power  of  assimilation  is  diminished;  thus  con- 
gestion and  enlargement  of  the  internal  organs,  intestinal  catarrh, 
bronchitis,  and  the  like  are  common  accompaniments  of  the  disease. 
The  most  marked  and  characteristic  changes  are  in  the  bones;  these 
consist  in  a  diminution  of  the  earthy  substances  and  in  overgrowth 
of  osteoid  tissue. 

"The  essential  features  of  the  morbid  processes  are,  first,  an 
exaggeration  of  the  processes  immediately  preparatory  to  the 
development  of  true  bone;  secondly,  an  imperfect  conversion  of 
this  preparatory  tissue  into  true  bone;  and  thirdly,  a  great  irregu- 
larity of  the  whole  process."     (Erichsen.) 

On  section  of  rhachitic  bone  it  will  be  noted  that  the  periosteum 
is  increased  in  thickness,  and  is  adherent  to  the  underlying  softened 
and  spongy  tissue.  The  medullary  canal  is  enlarged,  and  its  con- 
tents are  abnormally  vascular.  The  epiphyseal  cartilage,  normally 
a  thin,  bluish  line,  is  much  increased  in  thickness.  It  appears  to 
be  swollen  and  infiltrated,  and  it  has  lost  its  former  translucency. 
Microscopic  examination  at  this  point,  where  growth  is  most  active, 
shows  marked  irregularity  in  size  and  shape  of  the  columns  of  car- 
tilage cells;  the  zone  of  calcification  is  lacking  or  is  ill-defined,  and 
masses  of  cartilage  cells  are  found  unchanged  in  what  should  be  the 
area  of  true  bone.  The  same  irregularity  of  line  and  shape  is 
observed  in  the  medullary  spaces  of  the  newly  formed  osteoid  tissue. 

As  a  direct  result  of  the  changes  that  have  been  described,  the 
epiphyseal  junctions  are  enlarged  and  the  shafts  of  the  bones  are 
thickened  by  the  formation  of  osteoid  tissue  beneath  the  periosteum. 
The  indirect  effects  of  the  disease,  and  of  the  weakness  that  it  causes 
are  deformities,  the  nature  of  which  wdll  be  indicated  under  the 
heading  of  S^^llptoms.  The  stage  of  weakness  is  followed  by  that  of 
repair,  which  sometimes  goes  on  with  great  rapidity;  the  softened 
bones  become  abnormally  hard,  "eburnated,"  and  premature 
solidification  at  the  epiphyseal  junctions  may  be  one  of  the  remote 
results  of  the  disease  that  accounts  in  part  for  the  dwarfing  of  the 
stature,  observed  as  one  of  the  final  results  of  severe  rhachitis. 

Symptoms. — As  the  disease  is  the  effect  of  imperfect  assimilation 
its  more  pronounced  symptoms  are  preceded  by  those  of  indigestion, 
such  as  flatulence,  constipation,  and  the  like.  Profuse  perspiration, 
especially  about  the  head,  and  restlessness  at  night  are  common 
sjrmptoms.  Teething  is  often  delayed  or  is  irregular.  The  infant 
is  slow  in  its  movements,  and  makes  little  eft'ort  to  stand  or  to  walk 
at  the  usual  time,  and  if  the  disease  is  active  the  affected  parts  may 
be  sensitive  to  pressure. 

Deformities. — One  of  the  earliest  and  most  constant  evidences 
of  rhachitis  is  the  enlargement  about  the  epiphyseal  junctions,  an 
enlargement  caused  in  part  by  the  direct  hypertrophy  and  in  part 
by  pressure  upon  the  softened  tissues.  The  enlargements  at  the 
junctions  of  the  ribs  and  the  costal  cartilages,  the  rhachitic  rosary, 


RHACHITIS 


511 


and  at  the  wrists  and  ankles,  double  joints,  are  almost  invariably 
present  in  well-marked  cases.  The  more  general  distortions  are  in 
part  the  effect  of  atmospheric  pressure,  in  part  the  effect  of  the  force 
of  gravity  and  habitual  postures,  and  in  some  instances  muscular 
action  or  injury  may  deform  the  softened  bones.  These  deformities 
differ  greatly  according  to  the  time  of  onset  of  the  disease,  and  with 
its  duration  and  severity.  The  head  may  be  oblong  in  shape,  or 
rectangular,  capid  quadratum,  and  it  sometimes  presents  promi- 
nences in  the  frontal  and  parietal  regions  due  to  thickening  of  the 
bone,  and  on  the  posterior  aspect  depressed  and  softened  areas, 
craniotabes.  The  fontanelles  are  abnormally  large,  and  they  may 
remain  open  long  after  the  usual  time  of  closure. 


Fig.  384. — General  rhachitic  deformities,  showing  distortions  of  the  arms  and  leg 

induced  by  posture. 


The  thorax  is  compressed  from  side  to  side,  the  compression  being 
most  marked  in  the  middle  region,  where  the  ribs  have  the  longest 
cartilages  and  the  least  direct  support.  As  secondary  results  the 
back  of  the  thorax  is  flattened  and  the  sternum  is  thrust  forward 
forming  the  pigeon  breast.  The  lower  ribs  are  everted  to  accom- 
modate the  distended  abdomen,  pot  belly.  In  well-marked  cases  the 
rhachitic  chest  presents  two  distinct  grooves :  one  transverse  in  the 
axillary  line,  Harrison's  groove,  and  the  other  passing  upward  by  the 
side  of  the  rhachitic  rosary.     These  deformities  are  in  great  degree 


512 


CONGENITAL  AND  ACQUIRED  AFFECTIONS 


caused  by  atmospheric  pressure,  but  they  are  increased  if  the  child 
assumes  the  sitting  posture  habitually.  In  this  attitude  the  body 
is  inclined  forward,  the  clavicles  are  distorted,  and  the  spine  is  bent 
into  a  more  or  less  rigid  posterior  curve,  most  marked  in  the  lower 
dorsal  and  lumbar  regions,  the  rhachitic  kyphosis.  Less  often  there 
may  be  a  lateral  deviation  or  scoliosis. 

The  arms  may  be  distorted  by  the  efforts  of  the  child  to  support 
the  body  in  the  sitting  posture,  or  by  active  exertion,  as  in  creeping 
(Fig.  384).  Occasionally  the  deformity  may  be  localized  at  the 
elbow,  and  sufficiently  marked  to  merit  the  name  cubitus  varus  or 

valgus,  corresponding  to  genu  valgum 
or  varum;  or  the  principal  distortion 
may  be  a  dorsal  convexity  of  the  lower 
extremity  of  the  radius. 

Spindle-shaped  phalanges  are  some- 
times noted  among  the  early  signs  of 
rhachitis  in  young  children.^ 

The  bones  of  the  lower  extremities 
are  often  distorted,  primarily  by  the 
habitual  postures  assumed  in  sitting  or 
creeping,  and  these  deformities  are  us- 
ually exaggerated  when  the  erect  attitude 
is  assumed.  In  some  instances  it  would 
appear  that  the  femoral  necks  are  twisted 
backward  somewhat;  this  distortion,  in- 
duced apparently  by  the  cross-legged 
attitude  of  sitting  may  explain  in  part 
the  limitation  of  inward  rotation  that 
is  sometimes  observed  in  rhachitic  chil- 
dren. Depression  of  the  femoral  neck 
(coxa  vara)  may  be  present  also,  al- 
though this  deformity  does  not,  as  a 
rule,  attract  attention  until  a  much  later 
period  of  life.  The  changes  in  the  pelvis 
are  of  special  interest  to  the  obstetri- 
cian. These  are  essentially  an  increase  in  the  sacrovertebral 
prominence  due  to  the  forward  and  downward  displacement  of 
the  sacrum,  an  abnormal  expansion  of  the  ilia,  caused  by  pressure 
of  the  abdominal  contents,  and,  in  some  instances,  a  decrease  of 
the  lateral  diameter,  an  effect  of  the  pressure  of  the  femora  upon  the 
yielding  bone. 

In  the  milder  type  of  rhachitis  in  older  children  w^ho  walk,  the 
deformities  are  often  confined  to  the  trunk  and  lower  extremities. 
In  such  cases,  in  addition  to  the  changes  in  the  bones,  there  is  usually 
a  prominent  abdomen  and  increased  lordosis,  combined  with  slight 
habitual  flexion  at  the  hips  and  knees,  the  rhachitic  attitude. 


Fig.  385.  —  Typical    rhachitic 
deformities  of  mild  degree. 


iNeurath:  Wien.  klin.,  xl,  No.  1617. 


RHACHITIS 


513 


If  the  disease  is  severe  and  general  in  its  manifestations  it  may  be 
accompanied  by  pain,  by  sensitiveness  of  the  affected  bones,  and  by 


Fig.  386. — Rhachitic  coxa  vara. 


33 


514  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

such  weakness  of  the  lower  extremities  as  may  simulate  paralysis, 
rhachitic  'psendoyaralysis.  It  is  probable,  however,  that  the  cases 
in  which  the  pain  is  extreme,  "acute  rhachitis,"  are,  in  reality, 
scurvj''  or  scurw  and  rhachitis  combined,  scurvy  rickets  so-called. 

Rhachitis,  as  described,  is  the  type  ordinarily  seen  in  hospital 
practice,  and  its  manifestations  are  unmistakable.  In  its  milder 
form  it  is  not  uncommon  among  the  children  of  the  well-to-do 
whose  hygienic  surroundings  are  good.  In  such  cases  the  most 
marked  symptom  is  weakness.  The  child  is  often  fat  and  well 
developed,  although,  as  a  rule,  pale.  The  abdomen  is  somewhat 
enlarged  and  slight  prominences  at  the  epiphyseal  junctions,  par- 
ticularly at  the  wrists,  may  be  made  out.  The  legs  appear  small 
in  proportion  to  the  body,  and  the  ligaments  are  lax,  so  that  if  the 
child  stands  the  feet  are  flat  and  assume  the  attitude  of  valgus.  In 
this  class,  in  which  the  child  is  said  to  have  weak  ankles,  knock- 
knee  is  common. 

The  most  common  s^inptom  of  rhachitis  of  the  mild  type  is  the 
failure  of  the  child  to  attempt  to  walk  at  the  usual  time,  about 
sixteen  months.  A  child  of  normal  intelligence  who  is  not  ill  and 
who  has  not  suffered  from  exliausting  disease  and  does  not  walk  at 
two  years  of  age  is  probably  rhachitic. 

Prognosis. — The  duration  of  the  progressive  stage  of  rhachitis 
depends,  of  course,  upon  the  age  of  the  patient  and  upon  the  treat- 
ment. In  cases  that  are  untreated  and  in  which  the  predisposing 
causes  continue,  the  period  of  repair  may  be  delayed  for  several 
years  or  longer,  as  shown  by  the  fact  that  the  child  makes  little 
effort  to  stand.  But,  in  most  instances,  the  rhachitic  child  begins 
to  walk  during  the  third  year,  and  at  this  time,  the  deformities  of 
the  lower  extremity,  knock-knee,  bow-leg,  flat-foot,  and  the  like 
usually  develop  or  become  aggravated,  while  those  of  the  upper 
extremity  may  become  less  noticable 

The  deformities  of  rhachitis  tend  to  disappear  or  to  become  less 
marked  with  growth;  the  concavities  of  the  distorted  shafts  are 
filled  by  accretions  of  periosteal  bone,  which  is  again  absorbed  from 
the  interior  as  the  medullary  canal  straightens  itself.  The  thickened 
diaphyses  and  enlarged  epiphyses  become  more  symmetrical  under 
the  influences  of  rapid  growth  and  increased  functional  activity, 
but  traces  of  severe  rhachitis  always  remain,  and  many  of  the  more 
noticeable  and  permanent  distortions  of  the  trunk  and  of  the  lower 
extremities  are  due  to  this  cause. 

The  prognosis  as  to  the  outgrowth  of  rhachitic  deformities 
depends  upon  the  duration  and  the  severity  of  the  disease  and  upon 
the  function  of  the  deformed  part.  Rhachitic  distortions  of  the  arms 
almost  always  disappear  under  the  influence  of  the  force  of  gravity. 
The  rhachitic  chest  is  rarely  seen  in  the  adolescent  or  adult.  The 
rhachitic  kyphosis  is  corrected  or  modified  when  the  erect  posture 
is   assumed,   but  rhachitic   scoliosis,   on  the   other  hand,  usually 


LATE  RICKETS  515 

increases  with  the  growth.  Distortions  of  the  lower  extremities 
may  occasionally  entirely  disappear,  and  in  most  cases  they  are  less 
marked  in  the  adult  than  in  the  child.  Stunting  of  the  growth  is  a 
constant  effect  of  severe  and  prolonged  rhachitis ;  it  depends  in  part 
upon  the  arrest  of  development  and  deformity  during  the  active 
stage  of  disease  and  in  part  upon  premature  consolidation  at  the 
epiphyseal  junctions. 

Treatment. — The  treatment  of  rhachitis  consists  essentially  in  a 
reversal  of  the  conditions  under  which  it  developed.  It  is  therefore 
dietetic,  hygienic,  and  medicinal.  Deformity,  the  effect  of  the 
disease,  may  be  prevented  by  guarding  the  weakened  bones  from 
overstrain,  and  it  may  be  remedied,  if  it  be  present,  by  manipulation 
or  by  mechanical  or  by  operative  treatment. 

The  more  detailed  treatment  of  rhachitis  may  be  found  in  works 
on  pediatrics.  In  general,  the  diet  in  the  cases  developing  in  early 
infancy  should  be  of  milk,  especially  modified  according  to  the  need 
of  the  patient.  At  a  later  time,  corresponding  to  the  normal  period 
of  weaning,  the  diet  should  be  largely  animal,  to  the  exclusion  of 
starchy  food,  cream  and  fresh  butter  being  especially  valuable. 

The  patient,  protected  by  proper  woollen  underclothing,  should 
pass  as  much  time  as  possible  in  the  open  air,  and  should  sleep  in  a 
well- ventilated  room.  Daily  salt  baths  are  recommended  for  older 
children,  and  regular  massage  of  the  extremities  and  of  the  abdomen 
should  be  employed.  Medicinal  treatment  is  of  secondary  impor- 
tance. The  bowels  should  be  regulated  and  digestion  should  be 
aided  by  proper  remedies.  For  anemia,  which  is  usually  present, 
the  syrup  of  the  iodide  of  iron  is  of  value;  cod-liver  oil  serves  both 
as  a  food  and  medicine,  when  it  is  readily  assimilated.  It  is  unlikely 
that  any  drug  has  a  very  direct  influence  on  the  disease.  Phos- 
phorus in  doses  of  j^-q  to  y^  q-  of  a  grain  is  often  given,  and  is  supposed 
to  lessen  the  abnormal  congestion  of  the  bones,  while  the  deficiency 
of  lime  salts  may  be  supplied  possibly  by  the  administration  of  lime 
in  some  form,  the  syrup  of  the  lactophosphate  of  lime  being  a  favorite 
prescription. 

The  prevention  of  deformity,  other  than  by  the  means  already 
enumerated,  consists  in  preventing  habitual  postures  that  predis- 
pose to  deformity,  and  in  daily  massage  and  manipulative  correction 
of  incipient  distortions.  Young  infants  and  those  whose  bones  are 
especially  vulnerable  should  spend  much  of  the  time  in  the  reclining 
posture.  The  stretcher  frame  or  similar  appliance  is  especially 
useful  in  the  treatment  of  this  class  of  cases.  The  treatment  of  the 
more  advanced  deformities,  by  braces  or  by  operation,  is  described 
elsewhere. 

"LATE  RICKETS." 

Late  rickets  is,  as  the  name  implies,  an  affection  presenting  all 
the  characteristics  of  the  common  infantile  form.     This,  in  rare 


516  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

instances,  appears  in  later  childhood  or  even  in  adolescence ;  in  most 
instances  the  affection  appears  to  be  a  continuation  or  recrudescence 
of  the  infantile  form;  in  others  no  history  of  a  preceding  affection 
can  be  obtained.^ 

Adolescence  when  growth  is  rapid  is  a  period  of  instability  when 
static  deformities  develop,  or  if  already  present  are  exaggerated 
particularly  m  subjects  living  under  unfavorable  conditions  who  are 
overburdened  or  overworked. 

By  many  ^^Titers  the  term  late  rickets  is  improperly  used  to 
explain  genu  valgum,  coxa  vara,  and  the  like  m  subjects  of  this 
class,  although  none  of  the  distinctive  signs  of  the  disease  are  present. 

INFANTILE  SCORBUTUS. 

Synonyms. — Scurvy,  scurvy  rickets. 

Scur\y  in  infancy,  as  at  other  periods  of  life,  is  a  constitutional 
disease  dependent  upon  impaired  nutrition,  caused  apparently  by 
unsuitable  food.  The  disease  was  originally  described  by  Smith  and 
Barlow  as  scm*w  rickets,  but  it  may,  and  often  does,  occiu-  inde- 
pendently of  the  latter  affection. 

Pathology. — The  pathological  changes  ^most  often  found  in  cases 
of  the  advanced  tj^e  are  hemorrhages  beneath  the  mucous  mem- 
branes and  the  periosteum.  Separation  of  the  epiphyses  may  occur 
in  extreme  cases. 

Symptoms." — The  disease  is  most  often  seen  in  bottle-fed  infants 
from  six  to  eighteen  months  of  age  of  the  better  class,  fed  upon  steril- 
ized milk  or  for  whom  sterilized  milk  has  been  the  basis  of  the  diet. 
In  some  instances  the  patients  are  evidently  ill-nourished,  but  in 
others  they  may  appear  to  be  in  good  condition.  The  early  sjTup- 
toms  resemble  rheumatism.  The  child  shows  evidences  of  discom- 
fort when  certain  joints,  usually  of  the  lower  extremity,  are  moved, 
and  as  the  disease  progresses  it  may  scream  whenever  it  is  turned 
or  lifted.  The  painful  joints  are  sensitive  to  pressure  and  they  may 
be  somewhat  enlarged,  but  local  heat  and  redness,  as  well  as  fever, 
are,  as  a  rule,  absent.  After  dentition  the  gums  may  be  swollen 
and  spongy,  and  hemorrhages  into  the  skin  or  beneath  the  mucous 
membranes  may  occur.  In  extreme  cases  the  swelling  about  a  joint 
due  to  effusion  of  blood  and  accompanied,  it  may  be,  by  separation 
of  the  epiphyses  may  be  mistaken  for  the  s^Tnptoms  of  infectious 
epiphysitis  or  even  for  sarcoma. 

Treatment.- — The  treatment  consists  primarily  in  the  regulation 
of  the  diet,  particularly  in  the  substitution  of  fresh  uncooked  milk, 
properly  modified,  for  the  patient  food  or  sterilized  milk  that  may 
have  been  employed.     This   should   be  supplemented  by  orange 

iDrewitt:  Tr.  London  Path.  Soc,  1881,  xxxii;  Glutton:  St.  Thomas'  Hosp. 
Reports,  1884,  xiv;  Horwitz:  Am.  Jour.  Orthop.  Surg.,  November,  1909;  Emslie: 
St.  Bartholomew's  Hosp.  Rep.,  1906,  xlii. 


CHONDROD  Y STROP  HI  A 


517 


juice  or  that  of  other  fresh  fruit.  The  change  of  diet  usually  relieves 
the  symptoms.  During  the  painful  stage  of  the  disease  complete 
rest  in  the  horizontal  position  on  a  pillow  or  frame  may  be  indicated; 
later,  massage  of  the  limbs  and  back  may  be  of  service  in  improving 
the  nutrition  and  remedying  slight  deformity. 

CHONDROD  YSTROPHIA . 

Cases  that  present  the  signs  of  what  appears  to  be  severe  general 
rhachitis  at  birth  are  not  especially  uncommon.     The  trunk  seems 


Fig.  387. 


-Chondrodystrophia  in 
infancy. 


Fig.  388.  —  Chondrodystrophia, 
age  four  and  three-fourth  years; 
height,  34  inches;  normal  height,  41 
inches.     (See  Fig.  389.) 


long  and  the  upper  arms  and  thighs  are  disproportionally  short  and 
distorted,  as  compared  to  length  of  the  stunted  limbs.  The  head 
is  large.  The  face  is  flattened,  the  nose  sunken  and  the  skin  may  be 
thickened,  the  chest  presents  a  pigeon-like  distortion,  and  the 
extremities  of  the  bones  appear  to  be  generally  enlarged.     The 


518 


CONGENITAL  AND  ACQUIRED  AFFECTIONS 


hands  and  feet  are  short  and  broad  and  the  joints  seem  relaxed.  In 
some  instances  the  back  is  curved  into  a  rigid  kyphosis  or  scoHosis, 
and  restricted  motion  or  apparent  fixation  of  many  of  the  joints 
may  be'  present.^ 

Etiology  and  Pathology. — These  cases  were  formerly  supposed 
to  be  instances  of  intra-uterine  rhachitis.  Chondrodystrophia  is 
not,  however,  the  result  of  a  disturbance  of  nutrition;  it  is  due  appar- 


FiG.  389. — Chondrodystrophia  .-c-iay  picture  of  patient  Fig.  388,  showing  the 
characteristic  changes  in  the  diaphyses  of  the  upper  extremities  contrasted  with  the 
comparative  symmetry  of  the  trunk. 

ently  to  a  congenital  defect  or  interference  with  the  development  of 
the  cartilaginous  skeleton  beginning  at  different  periods  of  intra- 
uterme  life,  the  apparent  enlargement  at  the  joints  being  due  to 
formation  of  periosteal  bone  at  the  diaphyseal  extremities.  Rha- 
chitis is  characterized  by  thickening  about  the  epiphyseal  cartilages 
and  by  delayed  ossification.  In  chondrodystrophia,  on  the  con- 
trary, there  is  atrophy  of  the  epiphyseal  cartilages.  On  section 
of  a  bone  the  shaft  is  seen  to  be  thickened,  stunted,  and  irregular  in 
outline.  The  epiphyses  are  often  of  normal  size  and  consistency 
but  the  connecting  cartilage  is  irregular  and  atrophied. 

1  Roos:  Ztschr.  f.  klin.  Med.,  xh-iii;  Schirmer:  Centralbl.  f.  d.  Grenzgeb.  d.  Med. 
u.  Chir.,  1907,  No.  10. 


CHONDROD  YSTROPHIA 


519 


Chondrodystrophia  is  sometimes  seen  (Fig.  390)  in  a  very  mild 
form;  the   appearance   of   the   child   suggests   rhachitis,    but   the 


Fig.  390. — Chondrodystrophia  of  slight  degree,  contrasted  with  ordinary  rhachitis, 
in  sisters.  1.  Chondrodystrophia.  Broad,  short,  very  flexible  hands;  trunk  dispro- 
portionately long;  knock-knees.  Age,  five  and  a  half  years;  height,  30 1  inches; 
normal  height,  40  inches.  2.  Rhachitis,  bow-legs;  age,  four  years;  height  32  inches; 
normal  height,  36  inches. 


Fig.  391. — Cretinism  in  infancy. 


520  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

stunting  of  the  growth  is  greater  than  is  ever  the  result  of  rhachitis 
of  corresponding  severity. 

Cretinism. — Cretinism  may  cause  a  similar  dwarfing  of  the 
stature,  and  may  be  combined  with  chondrodystrophia,  but  the 
symptoms  of  mental  deficiency  that  accompany  cretinism  are 
lacking  in  this  affection  (Fig.  391). 

Prognosis. — By  persistent  treatment  the  range  of  motion  in  the 
stiffened  joints  may  be  regained.  The  more  extreme  distortions 
of  the  limbs  disappear  in  the  process  of  development.  The  patient 
is,  however,  dwarfed,  the  average  height  in  adult  age  according  to 
Schirmier  being  from  33  to  53  inches,  the  large  head  and  the  stunted 
extremities  indicating  the  cause. 

Treatment. — The  treatment  of  chondrodystrophia  consists  in 
regular  massage  and  manipulation  of  the  distorted  parts  and  of 
the  anchylosed  joints.  If  the  deformity  of  the  spine  is  extreme 
and  if  the  joints  are  weak,  rest  on  the  stretcher  frame  is  advisable. 
If  congenital  cretinism  is  suspected  the  administration  of  tlwroid 
extract  is  indicated. 

DYSCHONDROPLASIA. 

Dvschondroplasia  was  first  described  under  this  title  by  Oilier  in 
1898.1 

It  is  a  chronic  disease  of  the  bones  resembling  in  some  degree  the 
local  changes  of  chondrodystrophia,  but  irregular  in  its  distribution, 
often  limited  to  one  side  of  the  body,  which  is  otherwise  normal  in 
appearance. 

It  apparently  begins  at  an  early  stage  of  ossification  and  causes 
deformity,  shortening  and  often  the  formation  of  exostoses.  As  the 
disease  does  not  as  a  rule  cause  discomfort,  attention  is  first  attracted 
to  hard  lumps  on  the  arm  or  leg  or  to  the  shortening  of  a  lower  limb. 
X-ray  examination  shows  the  aft'ected  bone  usually  enlarged  and 
irregular  at  one  or  both  of  the  articulating  extremities,  with  areas 
of  expansion  and  lessened  density  of  the  shaft. 

A  number  of  bones  are  usually  involved,  including  often  several 
of  the  long  bones  of  the  hand,  of  which  the  cortex  may  be  expanded 
to  form  exostoses.  It  is  much  more  common  in  males  than  in 
females  and  often  occurs  in  successive  generations  of  the  same 
family.^ 

OSTEITIS  FIBROSA. 

Osteitis  fibrosa  is  a  clironic  disease,  characterized  by  fibrous 
transformation  of  the  marrow,  often  by  cyst  formation,  by  expan- 
sion, weakening  and  deformity  of  the  affected  bone. 

1  Lyon  Med. 

2  Ehrenfried:    Am.  Jour.  Orth.  Surg.,  June,  1917. 


OSTEITIS  FIBROSA  521 

"Histologically,  it  is  a  circumscribed,  endosteal,  fibrogenous, 
osteoplastic  metaplasia."  Metaplasia  implying  the  transformation 
of  one  kind  of  tissue  into  another  of  the  same  embryological  type. 
Thus  the  marrow  changes  to  fibrous  tissue  or  to  mucoid  or  to  fatty 
material,  or  into  cartilage  or  bone. 

The  disease  may  involve  many  bones,  or  it  may  be  limited  to 
one.  Its  common  site  is  the  upper  or  lower  extremity  of  the  femur 
or  humerus.     The  affected  bone  is  usually  enlarged,  weakened  and 


Fig.  392. — Osteitis  fibrosa. 

often  deformed  under  the  strain  of  weight-bearing.  There  is  slight 
local  discomfort  and  sometimes  sensitiveness  to  pressure.  The 
diagnosis  is  made  by  a:-ray  examination  which  shows  the  degenera- 
tive changes  described,  usually  well  defined  from  the  surrounding 
healthy  tissue,  thus  distinguishing  it  from  sarcoma. 

If  the  disease  is  localized,  thorough  removal  of  the  affected  area 
is  indicated.  In  any  case  the  weakened  part  should  be  protected 
to  prevent  deformity  or  fracture. 


522  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

MULTIPLE  MYELOMA. 

■'Multiple  myeloma  is  a  primary  neoplasm  of  the  bone  marrow 
affecting  chiefly  the  vertebrae,  ribs  and  sternum,  the  substance  of 
the  bone  being  replaced  by  tumor  tissue." 

The  disease  is  usually  one  of  later  life.  It  is  attended  by  discom- 
fort, by  deformity  and  often  by  fracture  of  the  affected  bones  which 
are  usually  irregular  in  outline  and  sensitive  to  pressure.  Emacia- 
tion and  disability  are  usually  rapidly  progressive.  Bence-Jones 
albumosuria  is  sometimes  present. 

Kahn  has  collected  61  cases  from  literature.^ 

FRAGILITAS  OSSIUM. 

Synonyms. — Idiopathic  osteopsathyrosis.  Osteogenesis  imper- 
fecta. 

Idiopathic  fragility  or  osteopsathyrosis  is  of  congenital  origin. 
The  bones,  particularly  those  of  the  lower  extremity,  are  delicate 
in  structure  and  usually  short.  The  epiphyseal  cartilages  appear 
to  be  relatively  normal  but  the  periosteal  growth  of  bone  is  deficient. 
The  bone  is  soft,  in  part  cartilaginous,  and  the  periosteal  tissue 
extends  into  its  substance.  In  such  cases  there  may  be  distortions 
at  birth,  apparently  caused  by  intra-uterine  fractures,  and  in  after- 
life fracture  may  follow  the  slightest  accident  or  even  ordinary 
movement.  Blanchard'  has  reported  a  case  in  which  there  were 
70  distinct  fractures  between  the  ages  of  two  months  and  twenty- 
seven  years.  A  similar  case  was  for  many  years  under  treatment  in 
the  Hospital  for  Ruptured  and  Crippled.  For  a  part  of  the  time 
the  trunk  and  legs  were  enclosed  in  a  plaster-of -Paris  casing  to  pre- 
vent the  fractures  that  followed  even  ordinary  movements.  At  the 
age  of  fourteen  the  strength  of  the  bones  had  increased  sufficiently 
to  enable  the  patient  to  walk  about  with  the  support  of  braces,  but 
in  stature  he  resembled  a  child  of  seven  years. 

Fractures  in  this  class  of  cases  are  attended  with  but  little  pain. 
They  unite  slowly  with  but  small  callus.  It  is  practically  impossible 
to  prevent  a  certain  amount  of  deformity.  With  advancing  years 
the  liability  to  fracture  may  diminish,  but,  as  a  rule,  the  patient  is 
disabled  and  dwarfed  in  stature. 

The  treatment  is  protective.  Massage,  the  Bier  treatment,  and 
the  like  may  be  of  some  service  in  improving  local  nutrition.  IMedi- 
cation  is  of  little  a  vail. ^ 

There  are  many  other  conditions  that  cause  local  or  general 
fragility  of  the  bones  and  thus  an  increased  liability  to  fracture. 

1  New  York  Med.  Rec,  May  9,  1914. 

2  Tr.  Am.  Orthop.  Assn.,  vi. 

3  Porak:  Bull,  et  Mem.  de  la  Soc.  Obst.  et  Gynee.  de  Paris,  1840;  Salvetti:  Beitr. 
z.  path.  Anat.  und  allg.  Path.,  1894,  xvi;  Nathan:  Am.  Jour.  Med.  Sc,  February, 
1905. 


OSTEOMALACIA  523 

Among  the  local  causes  are  tumors,  cysts,  inflammatory  processes, 
syphilis,  and  the  like.  The  general  conditions  would  include  the 
weakness  of  old  age,  and  the  condition  called  senile  rickets  or  osteo- 
malacia in  which  progressive  deformity  is  attended  by  pain;  the 
atrophy  caused  by  disuse  incidental  to  chronic  joint  disease,  or  the 
weakness  that  may  be  caused  by  certain  diseases  of  the  nervous 
system.  In  other  instances  the  weakening  may  be  the  direct  result 
of  disease,  as,  for  example,  osteomalacia  or  rhachitis. 

OSTEOMALACIA. 

Synonym. — Mollites  ossium. 

Osteomalacia  is  a  disease  of  an  inflammatory  nature,  characterized 
by  an  absorption  of  the  earthy  substances  (decalcification)  of  the 
bones  and  by  deformity.  The  disease  is  particularly  one  of  adult 
life.  It  is  far  more  common  among  females  than  males,  and  preg- 
nancy, in  about  half  of  the  cases  that  have  been  reported,  seemed  to 
be  the  exciting  cause.  The  disease  usually  begins  insidiously. 
The  symptoms  are  pain  on  motion,  referred  to  the  pelvis  and  to  the 
thighs.  This  is  supposed  to  be  of  rheumatic  origin  until  the  char- 
acter of  the  affection  is  made  evident  by  the  weakness  of  the  limbs 
and  by  the  deformities.  These  deformities  are  of  greater  interest 
to  the  obstetrician  than  to  the  surgeon,  for  when  the  affection  com- 
plicates pregnancy  the  distortion  of  the  pelvis  may  be  so  great  as  to 
prevent  normal  delivery. 

Osteomalacia  in  Childhood. — Three  cases  of  osteomalacia  in 
childhood  have  been  reported  by  Siegert,^  and  one  case  has  come 
under  my  observation.  The  patient,  one  of  twelve  living  children 
of  healthy  parents,  was  nursed  by  his  mother  for  the  usual  period, 
and  until  the  age  of  four  years  he  appeared  to  be  perfectly  healthy. 
At  this  time,  without  known  cause,  general  weakness  became 
apparent,  and  at  the  same  time  deformities  of  the  lower  extremities 
developed.  At  the  age  of  six  years  he  was  unable  to  stand.  The 
condition  of  the  patient  at  nine  years  of  age  is  shown  in  Fig.  393. 
The  patient  had  never  suffered  from  pain  or  discomfort.  The  lower 
extremities  were  somewhat  atrophied  from  disuse,  the  bones  were 
abnormally  flexible  and  were  distorted  to  a  moderate  degree.  The 
epiphyses  were  not  enlarged. 

Treatment. — As  the  etiology  of  the  affection  is  unknown,  the 
treatment  is  therefore  experimental  or  symptomatic  and  palliative. 

Local  Osteomalacia. — When  deformity  of  a  bone  appears  and 
increases  without  apparent  cause  it  is  often  assumed  that  a  local 
disease — "local  rickets  or  local  osteomalacia" — is  present. 

Local  weakness  and  deformity  may  be  caused  by  injury  or  by 
subacute  osteomyelitis  and  the  like.     If  there  is  a  distinct  local 

1  Miinchen.  med.  Wchnschr.,  November  1,   1898. 


524  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

disease  that  deserves  the  name  of  local  osteomalacia  its  cause  has 
not  been  determined. 


Fig.  393. — Osteomalacia  in  a  child. 


Fig.  394. — Osteitis  deformans  in  a  female  seventy-three  years  of  age.      (Lunn.i) 

OSTEITIS  DEFORMANS. 

This  disease  was  first  described  by  Paget^  in  1877.  It  is  a  chronic 
inflammatory  afi^ection  of  the  bones,  characterized  by  hypertrophy 
and  softening.  "The  bones  enlarge,  soften,  and  those  bearing 
weight  become  unnaturally  curved  and  misshapen." 

1  Prince:  Am.  Jour.  Med.  Sc,  November,  1902. 

2  Med.  Chir.  Tr.,  xl  and  Ixv. 


OSTEITIS  DEFORMANS 


525 


Section  of  an  affected  bone  shows  it  to  be  markedly  increased  in 
size,  and  somewhat  in  length,  by  a  combination  of  rarefying  and 
formative  osteitis.  The  inner  layers  become  porous,  and  at  the 
same  time  new  bone  is  deposited  beneath  the  periosteum. 

The  disease  appears  to  be  confined  to  adult  life,  and  it  is  appar- 
rently  more  common  among  males  than  females  and  in  rare  instances 
two  or  more  members  of  the  same  family  may  be  affected.  Of  67 
cases  collected  by  Packard,  Steele,  and  Kirkbride,^  61  per  cent  were 
in  males. 


Fig.  395. — Osteitis  del'onuaiis  of  both  femora  most  marked  on  the  right  side. 
Duration  of  symptoms  three  years.  Symptoms,  increasing  outward  bowing  of  the 
hmbs,  also  pain  and  weakness  after  overexertion. 


As  a  rule  the  lesions  are  symmetrical  and  general  in  distribution, 
the  bones  of  the  lower  extremity,  the  skull,  and  the  spine  being  more 
often  involved.  Thus  the  head  progressively  increases  in  size,  and 
the  legs  become  bowed.  If  the  spine  is  affected  it  bends  forward, 
forming  a  long,  more  or  less  rigid  kyphosis. 

1  Am.  Jour.  Med,  Sc,  November,  1901. 


526 


COXGEXITAL  AXD  ACQUIRED  AFFECTIONS 


Aside  from  the  deformities  and  the  characteristic  enlargement  of 
the  bones,  the  symptoms  are  not  marked.  At  times  complaint  is 
made  of  pain  nsually  supposed  to  be  rheumatic  until  the  character- 


FiG.  396. — Normal  tibia  and  foot. 


istic  changes  in  the  bones  appear.     The  disease  is  extremely  chronic 
in  its  course,  and,  as  a  rule,  the  general  health  is  not  seriously 


Fig.  397.- 


-Osteitis  deformans.      Hyperostosis  and  decalcification. 
Contrast  with  Fig.  396. 


(Fitz.) 


affected.  In  several  instances  sarcoma  of  bone  finally  caused  death 
many  years  after  the  onset  of  the  disease.  Its  etiology  is  unknown, 
and  its  treatment  is  palliative. 


SECONDARY  HYPERTROPHIC  OSTEO-ARTHROPATHY    527 

Local  Osteitis  Deformans. — A  disease  resembling  in  its  general 
characteristics  osteitis  deformans  may  appear  in  a  single  bone  or 
in  corresponding  bones  of  the  lower  extremity  (Fig.  395).  It  may 
persist  indefinitely,  with  but  little  tendency  toward  the  general 
involvement  of  the  bones  characteristic  of  Paget's  disease,  as  origi- 
nally described. 

The  treatment  is  symptomatic,  being  directed  especially  toward 
relief  of  strain  that  induces  discomfort  and  increases  the  deformity. 


SECONDARY  HYPERTROPHIC  OSTEO-ARTHROPATHY.^ 

Osteo-arthropathy  is  an  inflammatory  disease  of  the  bone  char- 
acterized by  hypertrophy,  clubbing  of  the  fingers,  and  effusion  into 
certain  of  the  joints.  The  hypertrophy  is  caused  by  a  deposition 
of  layers  of  bone  beneath  the  periosteum  of  the  metacarpal  and 
metatarsal  bones,  the  phalanges  and  the  distal  extremities  of  the 
adjoining  bones  of  the  arms  and  legs.  Less  often  the  area  of  the 
disease  is  more  extensive,  involving  the  femora,  the  humeri,  and 
even  the  spine. 

Osteo-arthropathy  is  most  common  in  young  subjects  and  is 
usually  a  complication  of  preexisting  chronic  disease,  which  causes 
interference  with  the  circulation  and  which  is  accompanied  by  sup- 
puration. Thus  it  is  most  often  found  in  combination  with  disease 
of  the  lungs,  as  in  65  of  93  cases  collected  by  Janeway.  The  clubbing 
of  the  terminal  phalanges  and  hypertrophy  of  the  finger-nails  first 
appear,  later  an  increasing  enlargement  of  the  wrists  and  ankles, 
and  of  the  hands  and  feet,  accompanied  by  discomfort,  sensitiveness 
to  pressure,  and  often  by  effusion  into  the  neighboring  joints, 
s\Tiiptoms  that  would  be  classed  as  rheumatic  were  it  not  for  the 
evident  hypertrophy. 

The  clubbing  of  the  fingers  is  due,  in  part  at  least,  to  impairment 
of  the  circulation,  and  the  connection  of  the  disease  of  the  bones 
with  that  of  the  lungs  has  suggested  the  theory  that  it  is  caused  by 
the  absorption  of  toxins,  and  that  its  etiology  is  similar  to  the 
amyloid  hypertrophy  of  the  internal  organs  that  sometimes  follows 
chronic  disease  of  bones  and  joints  attended  by  suppuration.  The 
treatment  is  sjTnptomatic,  and  as  the  affection  is  almost  always 
secondary  to  graver  disease,  but  little  is  known  of  its  outcome.  It 
is  certain,  however,  that  the  secondary  osteo-arthropathic  symptoms 
become  less  marked  or  may  even  disappear  as  the  patient  recovers 
from  the  original  disease  of  the  lungs  or  other  organs.  The  affec- 
tion is  very  uncommon  in  childhood.     In  one  characteristic  case 

1  Marie:  Rev.  Med.,  Paris,  1890,  x,  1;  Bamburger:  Wien.  klin.  Wchnschr.,  1889, 
No.  11;  Deutsch.  Chir.,  1899,  L.  28;  Alexander:  St.  Bartholomew's  Hosp.  Rep., 
1906,  xlii. 


528  CONGENITAL  AND  ACQUIRED  AFFECTIONS 

observed  by  the  writer^  complete  recovery  followed  the  cure  of 
Pott's  disease  and  chronic  bronchitis,  the  hypertrophied  phalanges 
alone  remaining. 

ACROMEGALY. 

This  affection  is  also  characterized  by  progressive  enlargement 
of  the  hands  and  feet,  but  it  differs  from  osteo-arthropathy  in  that 
all  the  tissues  are  hypertrophied.  The  hypertrophy  of  the  bone  is 
limited  to  the  extremities,  and  is  slight  compared  with  that  of  the 
soft  parts.  The  face  is  often  involved,  the  tissues  of  the  nose,  lips 
and  ears  being  enlarged  and  thickened,  together  with  the  underlying 
bones,  so  that  the  expression  is  markedly  changed.  The  affection 
most  often  appears  or  attracts  attention  in  early  adult  life.  It  is 
usually  slowly  progressive  and  it  may  be  accompanied  by  mental 
impairment. 

Acromegaly  is  common  among  those  of  gigantic  stature,  the  local 
hypertrophy  and  the  gigantism  both  being  due  to  increased  secre- 
tion of  the  pituitary  gland. 

"Two  conditions,  one  due  to  a  pathologically  increased  activity 
of  the  pars  anterior  of  the  hypophysis  (hyperpituitarism),  the  other 
to  a  diminished  activity  of  the  same  epithelial  structure  (hypopitu- 
itarism), seem  capable  of  clinical  differentiation. 

The  former  expresses  itself  chiefly  as  a  process  of  overgrowth — 
gigantism — when  originating  in  youth,  acromegaly  when  originating 
in  adult  life.  The  latter  expresses  itself  chiefly  as  an  excessive, 
often  a  rapid,  deposition  of  fat  with  persistence  of  infantile  sexual 
characteristics  when  the  process  dates  from  youth,  and  a  tendency 
toward  a  loss  of  the  acquired  signs  of  adolescence  when  it  first 
appears  in  adult  life"  (Cushing). 

1  "Whitman:  Pediatrics,  February  15,  1899;  Cushing:  Jour.  Am.  Med.  Assn., 
July  24.  1909. 


CHAPTER   XV. 

CONGENITAL  DISLOCATION  OF  THE  HIP  AND  COXA 

VARA. 

CONGENITAL  DISLOCATION  AT  THE  HIP-JOINT. 

Of  all*  the  congenital  dislocations,  or,  perhaps,  more  properly, 
misplacements,  that  of  the  hip-joint  is  by  far  the  most  common 
and  the  most  important. 

Statistics. — Congenital  dislocation  of  the  hip  is  much  more 
common  in  females  than  in  males.     In  1362  cases  collected  from 


Fig.  398. — Congenital  dislocation  of  the  hip,  showing  the  elongated  capsule  and  the 
right-angled  relation  of  the  neck  to  the  shaft  of  the  femur.      (William  Adams.) 

different  sources  by  Hoffa,  1189  (87.2  per  cent.)  were  in  females 
and  173  (12.7  per  cent.)  in  males.  Of  1039  cases  seen  at  the  Poly- 
clinic in  Milan,  867  (83.4  per  cent.)  were  in  females,  172  (16.6  per 
cent.)  in  males. ^  In  413  cases  from  the  Vienna  Institute,  344  (83.6 
per  cent.)  were  in  females,  69  (16.4  per  cent.)  in  males. 

1  Bernacchi:  Ztschr.  orthop.  Chir.,  ii,  275.     For  complete  review  of  the  literature 
see  Schultze:  Arch.  f.  Mechanotherapie  u.  unfall.  Chir.,  1908,  vii,  1.     For  statistics, 
Rev.  d'orthop.,  July  1,  1914. 
34 


530      CONGENITAL   DISLOCATION  OF  HIP  AND  COXA   VARA 

In  801  cases  from  the  records  of  the  Hospital  for  Ruptured  and 
Crippled,  655  (81.6  per  cent.)  were  in  females  and  146  (18.3  per  cent.) 
in  males. 

The  dislocation  is  more  often  unilateral  than  bilateral.  In  Hoffa's 
series  of  1362  cases,  860  (63.1  per  cent.)  were  single;  392  of  the  right, 
468  of  the  left  side.  In  502  cases  (36.9  per  cent.)  the  displacement 
was  bilateral. 

Statistics  of  801  Cases  of  Congenital  Dislocation  of  Hip,  Recorded  at  the 
Hospital  for  Rttptuhed  and  Crippled. 

Per  cent. 

Males 146  18.35 

Females 655  81 .  65 


801  100.00 

Right  hip 206 

Left  hip .35.3 

Both 231 

790  100.00 

Not  specified ' 11 

801 

Males. 

Right  hip 43  30.49 

Left  hip 55  39 .  02 

Both 43  30.49 


141  100.00 

Not  specified 5 

146 

Females. 

Right  hip 163  25.10 

Lefthip 298  45.94 

Both 188  28.96 


649  100.00 

Not  specified 6 

655 

The  dislocation  at  the  time  when  the  patients  are  brought  for 
treatment  is  usually  posterior,  upon  the  dorsum  of  the  ilium ;  in 
other  instances  it  is  anterior,  the  head  of  the  bone  presenting  below 
the  anterior  superior  pine.  It  is  probable,  however,  that  the  primary 
displacement  is  often  directly  upward,  for  in  those  cases  discovered 
in  infancy  this  position  is  common. 

Pathology. — The  pathological  anatomy  of  the  dislocation  was 
first  clearly  demonstrated  by  Dupuytren  in  1826,  and  since  1890, 
when  the  open  operation  was  first  performed,  the  exact  relation  and 
the  appearances  of  the  different  components  of  the  joint  have  been 
described  in  detail  by  Hoffa,  Lorenz,  and  other  operators. 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        531 


The  condition  of  the  joint  varies  with  the  age  of  the  patient 
and  the  strain  and  friction  to  which  the  displaced  parts  have  been 
subjected.  In  early  infancy  it  may  be  assumed  that  the  head  of  the 
bone  lies  in  close  proximity  to  what  is,  in  some  instances,  a  practi- 
cally normal  acetabulum;  in  others  to  one  that  is  somewhat  rudi- 
mentary, often  shallow  and  small,  sometimes  of  an  oval  or  of  a 
somewhat  triangular  shape.  The  acetabulum  is  covered  with  normal 
hyaline  cartilage,  the  ligamentum  teres  is  present,  and  the  capsule 
is  of  nearly  normal  structure.  At  a  later  time,  when  the  joint  is 
exposed*at  operation  at  the  age  of  five  or  more  years,  the  capacity 
of  the  rudimentary  acetabulum  is  lessened  by  a  deposit  of  fat  and 
fibrous  tissue.  As  a  rule,  however,  it  appears  to  be  of  fair  size  and 
depth.  The  capsule  is  elon- 
gated to  accommodate  the 
upward  displacement  of  the 
femur.  It  is  hypertrophied, 
especially  where  it  covers  the 
upper  part  of  the  head  of  the 
bone,  and  it  may  be  drawn 
into  shape  like  an  hour-glass; 
the  upper  part  contains  the 
head  of  the  femur;  the  ante- 
rior wall  is  drawn  tightly  across 
the  acetabulum,  forming  at  its 
upper  border  a  narrow  slit- 
like communication,  through 
which  the  ligamentum  teres 
passes  if  it  be  present  (Fig. 
399).  The  interior  of  the 
capsule  is  in  part  lined  with 
synovial  membrane,  and  it 
often  contains  more  synovial 
fluid  than  is  found  in  the 
normal  joint. 

The   ligamentum   teres,    al- 
though  probably  present  at 

birth  in  a  large  proportion  of  the  cases,  becomes  attenuated  and  ribbon- 
like with  the  increasing  elongation  of  the  capsule,  and  after  the  age  of 
five  years,  or  at  the  time  when  the  open  operation  is  performed,  it 
is  usually  absent,  and  far  more  often  in  the  bilateral  than  in  uni- 
lateral cases.  According  to  Lorenz,  in  52  cases  between  two  and  a 
half  and  five  years  it  was  present  in  17;  in  48  cases  beyond  the  age 
of  five  years  it  was  present  in  but  4.  In  rare  instances  it  may  be 
hypertrophied.  In  my  own  experience  the  ligament  is  present  in 
nearly  all  cases,  although  it  is  often  so  rudimentary  that  it  might 
easily  be  overlooked. 

A  shallow  secondary  acetahulum,  formed  in  part  by  the  direct 


Fig.  399. — Congenital  dislocation  of  the 
hip,  showing  the  original  and  the  acquired 
acetabula.     (Lorenz.) 


532       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

pressure  of  the  head  of  the  bone  through  the  adherent  capsule,  and 
in  part  the  result  of  irritation  of  the  periosteum,  is  usually  found 
upon  the  ilium  (Figs.  400  and  401),  but  it  is  not  often  of  sufficient 
depth  to  assure  a  secure  support  for  the  head  of  the  femur;  thus 
its  upper  margin  gradually  recedes  or  two  distinct  depressions  may 
be  formed,  one  above  the  other.  The  upper  extremity  of  the  femur 
is  usually  somewhat  atrophied.  The  neck  is  often  shorter  than 
normal,  and  its  angle  may  be  lessened,  and  in  many  instances  its 
forward  inclination  is  increased,  usually  by  anterior  torsion  of  the 


Fig.  400  Fig.  401 

Figs.  400  and  401. — Congenital  dislocation  of  the  hip  in  adult  age,  showing  the 
abnormal  shape  of  the  acetabulum,  the  depressions  in  the  ilium  caused  by  the 
pressure  and  friction  of  the  head  of  the  femur,  and  the  destructive  effect  of  this 
pressure  and  friction  upon  the  femur.     (Adams.) 

shaft.  At  birth  under  normal  conditions  the  anterior  inclination 
of  the  neck  is  about  35  degrees.  When  the  erect  posture  is  assumed 
the  pressure  on  the  tense  capsule  tends  to  force  the  neck  backward 
to  the  adult  angle  of  10  to  15  degrees.  As  this  influence  is  lacking 
if  the  femur  is  displaced  the  original  inclination  persists.  The  head 
of  the  femur  may  be  nearly  normal,  although  usually  it  is  somewhat 
flattened  on  its  posterior  and  under  surface,  or  it  may  be  somewhat 
conical,  acorn-like  in  shape,  or  again  compressed  from  side-to-side 
to  an  almond  shape  or  otherwise  distorted. 
There  are  secondary  changes  in  the  bones  of  the  pelvis.     In  uni- 


CONGENITAL  DISLOCATION  AT  THE  HIP-JOINT       533 

lateral  dislocation  the  pelvis  is  usually  somewhat  atrophied  on  the 
affected  side,  and  a  lateral  inclination  of  the  spine  may  be  present. 
The  final  changes  in  the  pelvis  caused  by  the  bilateral  dislocation 
are  more  important;  its  inclination  is  increased,  the  lumbar  lordosis 
is  exaggerated,  the  sacrum  is  forced  forward  and  downward  so  that 
the  anteroposterior  diameter  is  diminished;  the  tuberosities  of  the 
ischia  are  everted  and  the  transverse  diameter  of  both  the  inlet  and 
outlet  of  the  pelvis  is  increased. 

The  long  muscles  of  the  thigh  are  shortened,  while  those  attached 
to  the  pelvis  and  trochanter  are  changed  in  direction  and  are  usually 
lengthened.  There  is  also  a  slight  general  muscular  atrophy  that 
is  particularly  marked  in  the  gluteal  group. 

The  changes  that  have  been  described  are  in  part  congenital,  in 
part  accommodative,  and  in  part  due  to  the  influences  of  attrition 
and  injury,  to  which  the  abnormal  mobility  predisposes.  Thus, 
they  become  more  marked  with  increasing  age,  and  in  some  of  the 
adult  specimens  but  little  resemblance  to  the  normal  parts  remains 
(Figs.  400  and  401). 

As  a  rule  congenital  dislocation  of  the  hip  is  not  accompanied 
by  defective  development  or  deformity  elsewhere,  although  cases 
are  sometimes  seen  in  which  a  general  laxity  of  ligaments  is  present 
or  in  which  the  dislocation  may  be  one  of  a  series  of  deformities 
and  malformations. 

Etiology. — In  a  small  proportion  of  the  unilateral  cases  the  dis- 
location may  be  due  to  violence  at  birth,  but  the  fact  that  nearly 
85  per  cent,  of  the  patients  are  females  makes  it  evident  that  the 
primary  cause  can  be  neither  injury  nor  disease. 

Hereditary  influence  can  be  established  in  a  few  instances.  The 
writer  has  examined  3  female  children  in  a  family  of  9,  in  each  of 
whom  there  was  dislocation  of  the  left  hip,  the  order  being  the  third, 
eighth,  and  ninth  child.  Also  twins  in  another  family,  one  with 
single  and  the  other  with  double  dislocation.  And  in  4  instances 
congenital  displacement  was  present  in  the  mother  of  the  patients. 
Vogel,!  from  an  investigation  of  200  cases,  concludes  that  heredity 
might  have  had  some  remote  influence  in  30  per  cent. — viz. :  In  6 
instances  the  mother  had  congenital  dislocation,  in  9  the  father,  in 
7  sisters  of  the  father,  in  8  sisters  of  the  mother,  in  one,  both  father 
and  mother.  In  25  per  cent,  of  the  cases  there  had  been  breech 
presentation. 

Of  the  various  theories  that  have  been  advanced  to  account  for 
the  condition,  the  most  reasonable  seems  to  be  a  predisposing 
attitude  of  flexion  and  adduction  of  the  thigh  abnormally  prolonged. 
Dislocation  at  this  joint  is  relatively  frequent  because  the  acetabu- 
lum is  shallow  in  fetal  life,  four-tenths  as  compared  to  six-tenths  of  a 
sphere  in  adult  life.    Thus,  in  newborn  children  it  covers  but  one- 

1  Deutsch.  Ztschr.  f.  Chir.,  iii  and  iv,  71. 


534       CONGENITAL   DISLOCATION  OF  HIP  AND  COXA    VARA 

third  of  the  head  of  the  femur,  but  at  the  age  of  five  years  it  is  suffici- 
ently deep  to  contain  one-lialf  of  it. 

Heusner  and  ]\Iarcwald/  from  an  examination  of  85  fetuses,  con- 
ckide  that  the  greater  HabiHty  of  females  to  the  dislocation  is 
explained  by  the  disproportionate  laxity  of  the  capsule  as  compared 
with  males. 


Fig.  402. — Unilateral  dislocation, 
showing  the  inclination  of  the  body 
toward  the  shorter  limb. 


Fig.  433. — The  same  patient  before 
operation,  sho-wing  the  abnormal  lordosis 
and  rotation  of  the  pelvis.  (See  Figs.  430 
and  431.) 


It  is  probable  that  the  dislocation,  in  some  cases  at  least,  is  at 
bu'th  a  subluxation  only,  which  becomes  complete  through  muscular 
action  and  by  the  use  of  the  limb  in  standing  and  walking. 

Symptoms. — The  displacement  does  not,  as  a  rule,  attract  atten- 
tion until  the  child  begins  to  walk,  although  in  some  cases  the  mother 
may  have  noticed  a  peculiar  breadth  of  pelvis,  or  a  "lump"  on  the 
buttock,  or  a  "snapping,"  about  the  hip-joint,  or  a  peculiar  attitude 
of  the  limb  before  this  time. 


1  Ztschr.  f.  orthop.  Chir.,  1902,  Band  x,  Heft  4. 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT       535 

Unilateral  Dislocation. — If  the  displacement  is  of  one  side,  a  limy 
is  immediately  apparent,  which  becomes  more  noticeable  as  the  child 
grows  older.  The  limp  is  peculiar,  and  its  character  is  explained 
by  its  cause;  for  the  shortened  limb,  owing  to  the  elasticity  of  the 
capsule,  becomes  still  shorter  when  the  weight  falls  upon  it;  thus 
in  walking  there  is  a  peculiar  lunge  of  the  body  toward  the  short 
side,  that  has  been  likened  to  the  motion  in  walking  down  stairs. 
In  the  ordinary  form,  the  head  of  the  femur  is  displaced  upward  and 
backward,  and  in  compensation  the  pelvis  is  tilted  toward  the  short 
limb  and  its  inclination  is  increased;  it  is  thus  twisted  downward  and 
forward  so  that  the  anterosuperior  spine  lies  at  a  lower  level  and 
in  advance  of  that  of  the  opposite  side  (Figs.  402  and  403). 


iN^ 


Fig.  404. — Congenital  dislocation  in  an  adolescent,  illustrating  the  flexion  contrcc- 
tion  in  a  well-marked  case. 

At  an  early  age  the  shortening  of  the  limb,  due  to  the  elevation 
of  the  trochanter,  is  from  one-half  to  three-quarters  of  an  inch. 
In  later  childhood  the  elevation  is  from  one  and  one-half  to  two 
inches,  and  in  adult  life  it  may  be  considerably  more. 

The  effect  of  the  displacement  is  also  shown  by  a  flattening  of 
the  buttock,  and  usually  the  elevated  and  prominent  trochanter  may 
be  seen  as  an  abnormal  lateral  projection,  on  a  level  with  the 
anterosuperior  spine,  which  is,  as  has  been  stated,  somewhat 
tilted  downward*  In  infancy  motion  in  the  false  joint  is  more  free 
than  normal,  and  the  abnormal  mobility  can  be  demonstrated  by 
alternate  traction  and  upward  pressure  on  the  limb,  but  as  the 
femur  becomes  larger  and  the  upward  displacement  increases, 
the  mobility  is  restricted.  The  range  of  abduction  is  much 
diminished,  and  in  extreme  cases  the  limb  may  become  perman- 
ently adducted  and  flexed,  thus  adding  the  apparent  shortening 
of  adduction  to  that  caused  by  the  dislocation  (Fig.  404). 

Bilateral  Dislocation. — In  bilateral  dislocation  the  shortening  of 
the  limbs  is,  as  a  rule,  equal  or  nearly  so,  and  if,  as  is  usual,  both 
femora  are  displaced  backward,  the  pelvis  is  tilted  forward;  thus 
in  compensation  "the  hollow"  of  the  back  is  increased,  the  abdomen 


536       CONGENITAL  DISLOCATION   OF  HIP  AND  COXA   VARA 

protrudes,  the  buttocks  are  flattened,  the  pelvis  appears  to  be  abnor- 
mally wide,  and  the  thighs  are  separated  by  a  considerable  interval 
(Figs.  405  and  406).  The  limp  characteristic  of  the  single  displace- 
ment is  replaced  by  an  exaggerated  ivaddle,  a  "sailor  gait." 


Fig.  405. — Bilateral  congenital  dislocation  of  the  hip,  shomng  the  exaggerated 

lordosis; 

General  Symptoms. — In  early  childhood  there  are  no  special  sjTnp- 
toms  other  than  the  limp  or  the  waddle,  but  as  the  child  becomes 
more  active  it  often  complains  of  discomfort  after  exertion.  It  is 
easily  fatigued,  and  at  times  it  may  suffer  actual  pain.  These 
symptoms  are,  of  course,  more  marked  in  the  double  than  in  the 
single  displacement,  because  m  the  latter  case  the  normal  limb  is 
capable  of  bearing  more  than  its  share  of  the  strain.  The  symp- 
toms often  increase  during  adolescence,  but  they  may  become  less 
troublesome  in  adult  life,  when  the  head  of  the  bone  may  have  found 
a  permanent  resting  place  on  the  pelvis;  a  secm'ity  which  is  often 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT 


537 


assured  by  a  corresponding  limitation  of  the  range  of  motion. 
The  shortening  and  the  secondary  effects  of  the  displacement,  of 
course,  persist,  so  that  the  individual  is,  as  compared  with  the 
normal  standard,  more  or  less  disabled  and  in  certain  instances 
noticeably  deformed. 


Fig.  406. — Congenital  dislocation  of  both 
hips,  illustrating  the  separation  of  the  thighs, 
the  abnormal  breadth  of  the  pelvic  region, 
and  the  prominent  trochanters. 


Fig.  407.  —  Bilateral  anterior 
congenital  dislocation.  The 
lordosis  is  far  less  marked  than 
in  the  ordinary  form. 


The  great  majority  of  the  patients  are  females,  and,  because  of 
the  less  laborious  occupations  and  the  distinctive  dress,  the  dis- 
ability and  its  effects  are  less  serious  than  if  the  displacement  were 
more  equally  divided  between  the  sexes. 

Anterior  Dislocation. — The  symptoms  of  the  unilateral  anterior 
dislocation,  in  which  the  head  of  the  bone  lies  beneath  the  antero- 
superior  spine,  are  much  less  marked  than  in  the  ordinary  form 
because  the  relation  of  the  pelvis  to  the  femur  is  more  nearly  nor- 
mal. The  shortening  is  less  and  the  limp  is  less  noticeable  because 
the  resistance  of  the  tissues  attached  to  the  anterosuperior  spine 
is  sufficient  to  assure  a  relatively  secure  support. 


538      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

In  bilateral  anterior  dislocation  the  entire  body  is  swayed  slightly 
backward,  but  the  lumbar  lordosis  is  not  increased;  in  fact,  the  back 
is  often  peculiarly  flat.  Otherwise  the  symptoms  do  not  dift'er, 
except  in  degree,  from  those  of  the  posterior  displacement  (Fig. 
407). 

Supracotyloid  Displacement. — As  has  been  stated,  in  early  cases 
the  displacement  may  be  a  form  of  subluxation  in  which  the  head 
lies  but  slightly  above  the  normal  position.  The  same  upward 
displacement  is  occasionally  found  in  older  subjects.  The  physical 
signs  are  similar  to  those  of  the  anterior  displacement. 


Fig.  408. — Bilateral  congenital  dislocation  of  the  hip. 


Diagnosis. — The  diagnosis  offers  no  difficulty.  The  history  of 
the  limp  or  waddle  noticed  when  the  child  began  to  walk  and  yet 
unaccompanied  by  pain  or  preceded  by  injury  or  disease  is  in  itself 
sufficiently  distinctive.  If  the  displacement  is  of  one  side,  measure- 
ment demonstrates  the  shortening  as  compared  with  the  other  limb, 
a  shortening  that  is  explained  by  the  prominence  of  the  trochanter 
and  its  elevation  above  Xelaton's  line.  Traction  or  upward  pres- 
sure on  the  limb  will  demonstrate  the  abnormal  mobility  of  the 
displaced  head;  and  finally,  if  the  thigh  be  flexed  and  adducted  to 
its  extreme  limit,  the  neck  and  head  of  the  femur  can  be  easily  dis- 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        539 


tinguished  moving  under  the  gluteal  muscles  when  the  limb  is 
rotated.  Thus  it  may  be  differentiated  from  depression  of  the  neck 
of  the  femur  {coxa  mra),  in  which,  although  the  trochanter  is  ele- 
vated, the  neck  and  head  of  the  bone  cannot  be  felt,  and  in  which 
the  abnormal  mobility,  characteristic  of  the  dislocation,  is  absent. 
Again,  coxa  vara  is  almost  never  a 
congenital  aft'ection;  therefore  the 
history  itself  would  practically  ex- 
clude it. 

l^pw^rd  displacement  of  the  femur 
not  infrequently  follows  infectious 
eiyiphysitis  or  arthritis  of  infancy  or 
early  childhood.  In  such  cases  a 
part  of  the  upper  extremity  of  the 
bone  is  usually  destroyed,  so  that 
the  head  cannot  be  distinguished  on 
palpation.  Although  the  other  phys- 
ical signs  are  similar  to  those  of 
the  congenital  displacement,  the 
scars  about  the  joint  present  the 
evidence  of  former  disease,  and  the 
history  is  almost  always  available 
for  diagnosis.  Thus,  as  a  rule, 
such  disabilities,  as  well  as  traumatic 
dislocations  or  other  results  of  injury 
or  disease,  are  readily  excluded. 

The  bilateral  dislocation  presents, 
of  course,  the  same  physical  signs 
as  the  single  form;  it  is  even  more 
easily  recognized  by  the  peculiar 
appearance  and  distinctive  gait  of 
the  patient.  The  waddling  gait 
may  be  simulated  by  that  of  ex- 
treme boiv-legs,  but  the  hip- joints 
are,  in  this  deformity,  normal  in  ap- 
pearance and  function.  The  swag- 
ger of  lumbar  Pott's  disease  is  also 
somewhat  similar,  but  this  is  an  ac- 
quired painful  disease  of  the  spine,  in  which  the  hip- joints  are 
normal  in  appearance  and  usually  so  in  function. 

Progressive  muscular  dystrophy  may  be  mentioned  as  causing  a 
somewhat  similar  gait  and  attitude,  but  here  the  resemblance 
ceases. 

As  has  been  stated,  the  diagnosis  of  congenital  dislocation  can  be 
easily  made  by  physical  examination;  the  only  real  difficulty  is 
experienced  in  certain  dislocations  or  subluxations  of  the  anterior 
type  and  in  cases  seen  in  early  infancy  in  which  the  dislocation  may 


Fig.  409. — Bilateral  dislocation 
in  adolescence.  This  patient  was 
practically  disabled  by  pain  and 
weakness. 


540       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA 

be  incomplete,  but  opportunity  for  such  early  diagnosis  is  rarely 
offered.  In  doubtful  cases  a  Roentgen  picture  will  demonstrate 
the  character  of  the  disability  (Fig.  408). 

Treatment. — Dupuytren,  in  1829,  after  a  careful  study  of  the 
anatomy  of  the  deformity,  came  to  the  conclusion  that  it  was  not 
only  incurable  but  that  palliation  of  its  effects  even  was  hardly 
attainable;  and  for  sixty  years  the  statement  was  generally  accepted, 
although  cm-es  were  attained  in  all  probability  by  Pravaz,  of  Lyons, 
(1847),  and  certainly  at  a  much  later  time  by  Paci,  of  Pisa,  (1887). 

The  term  dislocation  naturally  suggests  replacement  and  reten- 
tion of  the  displaced  bone  in  its  proper  place,  and  in  1890  Hoff'a  first 
performed  this  operation  with  success  by  opening  the  joint  from 
behind  and  enlarging  the  rudimentary  acetabulum  to  a  size  sufficient 
to  contain  the  head  of  the  bone.  The  details  of  the  operation  were 
afterward  modified  by  Lorenz,^  and  at  the  present  time  the  original 
operation  has  been  to  a  great  extent  supplanted  by  bloodless  reposi- 
tion, but  to  Hoft'a  belongs  the  credit  for  the  introduction  of  the 
modern  treatment  of  this  disability. 

Treatment  by  the  Lorenz  Operation  of  Bloodless  Reduction, 
Retention,  and  Weight-bearing. — This  treatment  is  based  on  the 
experience  obtained  by  the  open  treatment  that  an  acetabuhmi 
of  fair  size  is  practically  always  present  and  of  sufficient  capacity 
to  retain  the  head  of  the  femur  if  the  limb  is  fixed  in  a  favorable 
attitude. 

It  has  been  proved,  also,  that  the  head  of  the  femur  in  most 
instances  may  be  forced  within  the  rudimentary  acetabulum. 
Once  this  contact  or  reposition  is  attamed,  the  limb  must  be  fixed 
to  prevent  displacement,  and  as  soon  as  possible  the  patient  must 
stand  and  walk  in  order  that  weight  and  friction  may  deepen  the 
rudimentary  acetabulum.  ^Meanwhile  the  capsule  and  other 
tissues  adapt  themselves  to  the  new  condition,  while  the  muscles 
regain  their  capacity  for  normal  function.  That  the  acetabulum 
may  be  actually  enlarged  by  the  presence  of  the  head  of  the  femur 
is  proved  by  the  fact  that  secondary  depressions  of  sufficient  size 
to  form  joints  of  fair  stability  are  often  found  upon  the  pelvis  in 
anatomical  specimens  from  older  subjects. 

The  Lorenz  Operation. — The  first  step  in  the  typical  operation  is 
to  overcome  the  resistance  of  the  tissues,  namely,  of  the  capsule 
and  of  the  long  muscles  that  have  become  structuraUy  shortened  in 
accommodation  to  the  upward  displacement  of  the  head  of  the 
femiu-.  The  second  step  is  to  reduce  the  dislocation,  or  rather  to 
force  the  head  of  the  femur  over  the  posterior  border  of  the  ace- 
tabulum. The  third  is  to  increase  the  security  of  the  articulation 
by  stretching  the  anterior  border  of  the  capsule.  The  fom'th  is  to 
fix  the  parts  securely  in  a  plaster  bandage. 

1  Pathologie  und  Therapie  der  Angebornen  Hiift.  Verrenkung,  Wien,  1895;  Ueber 
heilung  der  Angebornen  Hiiftgelenk  Verrenkung,  Leipzig  u.  Wien,  1900. 


CONGENITAL  DISLOCATION  AT   TEE  HIP-JOINT        541 

The  patient  is  placed  upon  a  table  with  a  thick  folded  sheet 
beneath  the  buttocks.  The  assistant,  standing  opposite  the  opera- 
tor, fixes  the  pelvis  with  his  hands  (Fig.  410).  In  some  instances 
better  control  is  assured  by  pressing  the  flexed  thigh  of  the  sound 
side  downward  against  the  abdomen,  as  in  the  Thomas  test  for 
flexion  in  hip  disease. 

The  operator  first  flexes  the  thigh  to  a  right  angle  with  the  body, 
then  forcibly  abducts  it,  at  the  same  time  kneading  the  tense  muscles 
with  the  ulnar  border  of  the  hand,  if  necessary  stretching  and  rup- 
turing the  fibres  until  the  limb  can  be  forced  down  to  the  plane  of  the 
body.  One  next  overcomes  the  shortening  of  the  tissues  on  the 
posterior  aspect  by  flexing  the  limb,  extended  at  the  knee,  upon  the 
trunk,  gradually  forcing  it  downward  until  the  toes  may  be  placed 


Fig.  410.— Reduction  of  dislocation  of  the  right  hip.     First  step.     The  operator 
overcomes  the  resistance  offered  by  the  adductors  by  forcible  massage. 

against  the  patient's  face  (Fig.  411).  During  this  maneuvre  the 
assistant  fixes  the  pelvis  by  holding  the  extended  thigh  of  the  sound 
side  firmly  against  the  table.  The  next  step  is  to  overcome  the 
resistance  of  the  tissues  on  the  front  of  the  joint.  The  pelvis  is 
fixed  by  the  assistant.  The  leg  is  then  flexed  upon  the  thigh,  and 
the  thigh  is  forced  downward  behind  the  plane  of  the  body,  or  the 
patient  may  be  turned  upon  the  side,  as  in  Fig.  412.  After  this 
preliminary  stretching,  traction  is  made  upon  the  limb,  and  if  with 
slight  effort  the  trochanter  can  be  drawn  down  to  Nekton's  line 
reduction  is  attempted. 

Reduction. — The  pelvig  having  been  fixed  as  in  the  first  position, 
the  limb  is  slowly  and  forcibly  abducted  over  a  wedge  of  wood 
suitably  padded,  the  apex  of  which  is  placed  between  the  trochanter 


542      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

and  the  pelvis  (Fig.  413).     As  the  Hmb  is  gradually  forced  downward 
to  and  behind  the  plane  of  the  body,  the  head  of  the  femur  is  forced 


Fig.  411. — Forcible  flexion  of  the  extended  limb  on  the  abdomen.    Second  step  in  the 

operation. 


Fig.  412. — Forcible  extension  of  the  thigh.     Third  step  in  the  operation. 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        543 

upward  until  it  finally  snaps  over  the  posterior  and  inferior  border 
of  the  acetabulum.  Reduction  is  usually  accompanied  by  a  dis- 
tinct jar,  and  often  by  an  audible  thud.  It  is  also  indicated  by 
tension  upon  the  hamstring  muscles,  which  causes  fixed  flexion  of 
the  leg.  The  patient  is  then  turned  upon  the  sound  side  and  the 
pelvis,  having  been  fixed  by  the  assistant,  the  operator  rotates  the 
limb  from  side  to  side  and  at  the  same  time  presses  the  trochanter 
downward  and  forward  with  the  aim  of  forcing  the  head  more  com- 
pletely within  the  acetabulum.  The  security  of  the  reposition  is 
then  determined.  One  tests  successively  the  stability  or  depth  of 
the  superior  margin  of  the  acetabulum  by  reducing  the  abduction; 
of  the  posterior  margin  by  lifting  the  thigh  ventralward,  and  in  a 
similar  manner  the  inferior  border.  Upon  this  examination  the 
prognosis  is  made;  if  the  stability  permits  an  approximation  to 
the  normal  position  before  displacement  occurs  the  prognosis  is 
good.  If,  on  the  other  hand,  the  margins  of  the  acetabulum  are 
so  ill-formed  that  displacement  occurs  very  easily  the  prognosis 
is  bad. 


Fig.  413. — Reposition.  The  thigh  is  forcibly  abducted  over  the  padded  wedge. 
Fourth  step  in  the  operation.  The  wedge  is  of  hard  wood  of  the  following  dimension: 
length,  9^  inches;  height,  3|  inches;  base,  3  inches. 

The  operation  is  varied  somewhat  in  certain  instances.  If  after 
the  stretching  the  trochanter  still  remains  above  Nelaton's  line, 
one  attempts  to  overcome  the  remaining  resistance  by  direct  trac- 
tion in  the  line  of  the  body.  Counter-resistance  is  furnished  by  a 
folded  sheet  passed  between  the  thighs  about  the  perineum,  the  two 
ends  of  which  are  tied  about  a  corner  of  the  table.  Traction  on  the 
limb  is  made  by  one  or  two  assistants  while  the  operator  supports 
the  pelvis  and  presses  downward  and  inward  upon  the  trochanter. 
Occasionally  reposition  is  effected  during  this  maneuvre — that  is, 
the  head  is  drawn  over  the  superior  instead  of  the  posterior  border 
of  the  acetabulum. 

Preliminary  Traction. — In  the  treatment  of  older  patients  or  of 
more  resistant  cases  preliminary  traction  in  bed  is  advisable.  The 
traction  must  be  considerable,  and  heavy  weights,  if  possible  up  to 


544      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

forty  pounds  or  more,  should  be  employed  for  two  or  more  weeks. 
This  is  of  great  advantage. 

Reduction  in  Two  Sittings. — If  the  reduction  proves  to  be  very 
difficult,  requiring  more  force  than  is  deemed  safe,  the  limb  should 
be  fixed  in  a  plaster  spica  in  the  attitude  of  abduction,  the  actual 
reposition  being  deferred  for  one  or  more  weeks.  At  the  second 
operation  the  reduction  can  be  easily  accomplished  in  most  instances. 

Reduction  in  Young  Subjects. — In  younger  subjects  the  wedge  is 
not  necessary,  the  thumb  of  the  operator  being  used  as  a  fulcrum 
beneath  the  trochanter  to  lift  and  push  the  head  upward  while  the 
limb  is  abducted.  Jn  this  class  of  cases  much  less  force  is  required 
in  the  preliminary  stretching,  rupture  of  the  adductors  is  not  required 
(Fig.  414)  and  in  the  treatment  of  very  young  subjects  reduction 
may  often  be  effected  by  simply  abducting  the  limb. 


Fig.  414. — Reposition  in  young  subjects,  the  thumb  being  used  as  the  fulcrum  to 

reduce  the  left  hip. 

After  reposition  has  been  accomplished  and  when  the  greatest 
possible  stability  has  been  assured  by  manipulation  the  plaster 
bandage  is  applied.  A  close-fitting  stockinette  shirt,  of  which  one- 
half  has  been  cut  and  sewed  to  cover  the  limb  as  a  drawer,  is  drawn 
on  over  the  limb,  threaded  as  it  were,  with  a  long  bandage,  the 
"scratcher."  The  patient  is  then  placed  upon  the  pelvic  rest  and 
the  limb  is  held  in  the  position  of  greatest  stability  at  a  right  angle 
with  the  trunk  and  lying  behind  the  plane  of  the  body.  The  pelvis 
and  thigh  are  thoroughly  and  thickly  covered  with  layers  of  sheet- 
wadding  or  cotton.  This  is  bandaged  firmly,  to  assure  a  slight 
elastic_compression*(Fig.  415). 


CONGENITAL  DISLOCATION  AT  THE  HIP-JOINT        545 

The  plaster  spica  is  then  appHed.  This  should  be  thick  and  firm. 
The  bandages  are  drawn  snugly  around  the  pelvis  and  thigh  by  a 
series  of  reverses  and  figure-of-eight  turns,  clasping  the  iliac  crests 
and  thoroughly  covering  in  the  buttock.  The  lower  part  is  cut  away 
to  permit  motion  at  the  knee-joint,  especial  care  being  taken  to 
evert  the  edges  and  thus  to  prevent  pressure.  The  ends  of  the 
shirting  are  then  drawn  smoothly  over  the  bandage  and  are  sewed 
to  one  another  (Figs.  416  and  417). 

The  operation  is  usually  followed  by  swelling  and  discoloration 
in  the  adductor  region  and  more  or  less  pain,  of  a  starting,  spasmodic 
character,  especially  when  the  leg  is  moved.  This  soon  passes 
away,  usually  during  the  first  or  second  week,  and  the  child  is  then 
encouraged  to  stand.  As  it  is  only  with  extreme  difficulty  that  the 
foot  on  the  operated  side  can  be  brought  to  the  floor,  a  cork-soled 
shoe  from  one  and  a  half  to  three  inches  in  height  is  usually  worn  to 
facilitate  walking. 


Fig.  415. — The  position  in  which  the  limb  is  held  when  the  plaster  bandage  is  applied. 


As  has  been  stated,  walking  is  encouraged  on  the  theory  that 
weight -bearing  and  the  stimulation  of  functional  activity  will  in- 
crease the  stability  of  the  joint  by  deepening  the  acetabulum  and 
accentuating  its  boundaries.  In  most  instances  the  range  of 
extension  at  the  knee  is  for  a  time  somewhat  restricted.  This 
restriction  is  overcome  by  passive  force  and  by  the  voluntary  effort 
of  the  patient.  The  first  bandage  is  retained  from  three  to  six 
months  or  for  a  longer  period,  the  skin  being  kept  in  good  condition 
by  daily  vigorous  rubbing  with  the  band  beneath  the  supporting 
bandage.  In  addition  the  leg  should  be  regularly  massaged;  after 
a  few  weeks  the  bandage  becomes  loose  about  the  pelvis.  This 
will  permit  rubbing  of  the  buttocks.  One  is  able  also  by  palpation 
of  the  anterior  region  to  ascertain  whether  or  not  the  head  of  the 
35 


5-lG      COXGEXITAL  DISLOCATIOX  OF  HIP  AXD   COXA    VARA 


^' . 

"^^H 

f  .yi 

^n 

I  M 

fei.^1 

\  ^^'1 

1  /^SiU 

I'!G._416. — A  plaster  bandage  applied  by  Lorenz,  illustrating  the  extreme  thickness 
of  the  pelvic  portion  and  discoloration  of  the  adductor  region. 


Fig.  417. — Unilateral  congenital  dislocation,  showing  the  fixation  bandage.  A 
shoe  with  a  cork  sole  about  two  inches  should  be  worn  on  the  operated  side,  while 
the  attitude  of  exaggerated  abduction  is  maintained. 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        547 

femur  is  in  proper  position.     In  young  children  the  bandage  must 
be  changed  as  often  as  it  becomes  offensive. 

In  six  months  or  when  it  may  be  supposed  that  the  accommoda- 
tive changes  of  the  muscles  about  the  joint  and  the  contraction  of 
the  capsule  will  prevent  redisplacement,  the  limb  is  let  down  some- 
what so  that  the  patient  is  able  to  walk  about  without  the  aid  of  a 
high  shoe.  The  second  bandage  is  retained  for  three  months  or 
more,  and  it  is  then  removed,  the  period  of  retention  being  from  six 
to  twelve  months,  according  to  the  stability  of  the  joint  at  the  time 
of  reduction.  In  the  treatment  of  very  young  children,  when  in 
testing  the  stability  at  the  time  of  operation  the  femur  is  not  dis- 
placed, even  w^hen  the  normal  position  is  approached,  the  limb  may 
be  fixed  by  the  plaster  in  a  less  distorted  attitude — what  Lorenz 
calls  the  indifferent  position  of  flexion,  abduction,  and  outward 
rotation . 


Fig.  418. — Illustrating  the  limitation  of  the  range  of  abduction  in  the  attitude  of 
right-angular  flexion  in  bilateral  dislocation. 

So,  also,  when  the  tests  at  the  operation  show  fair  stability  a 
second  bandage  need  not  be  applied  after  a  preliminary  retention 
of  from  six  months,  or  even  a  much  shorter  time  if  proper  super- 
vision can  be  provided,  but  it  is  better  to  err  on  the  side  of  safety 
in  the  matter  of  fixation. 

When  the  retention  bandage  is  finally  removed  the  attitude  of 
moderate  abduction  and  outward  rotation  persists  for  a  time,  in 
some  instances  for  several  months.  This  being  an  indication  of 
stability,  is  considered  a  favorable  sign,  and  no  attempt  is  made  to 
correct  it.  If,  on  the  other  hand,  as  in  the  older  class  of  patients, 
the  fixed  abduction  persists  the  patient  should  be  anesthetized  and 
the  contracted  tissues  carefully  stretched.  In  many  cases  of  this 
character  the  cause  of  the  distortion  is  a  partial  pubic  displacement, 
the  head  of  the  bone  forming  a  well-marked  projection  beneath  the 
femoral  artery.     This  projection  may  be  reduced  by  flexing  the 


548      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

limb,  and  in  certain  instances  it  may  be  well  to  fix  the  limb  for  a 
time  in  a  slightly  flexed  position  until  the  tendency  toward  the  an- 
terior displacement  is  lessened.  In  the  after-treatment  the  limb  is 
massaged,  particularly  the  posterior  and  lateral  muscles  of  the  hip, 
and  the  child  is  encouraged  to  abduct  and  to  extend  the  thigh,  and 
bearing  the  weight  on  the  operated  limb  to  sway  the  other  limb 
laterally  to  the  extreme  limit.  Passive  movements  are  made,  also, 
in  the  direction  of  abduction  and  extension,  the  ability  to  reproduce 
the  first  or  operation  position  during  the  early  treatment  being  con- 
sidered essential.  In  certain  instances  the  child  for  a  time  should 
sleep  in  this  position,  the  attitude  being  assured  by  placing  the  child 
in  a  support  of  plaster  corresponding  to  the  posterior  half  of  the 
original  spica. 


Fig.  419. — The  after-treatment  following  the  removal  of  the  plaster  spica  in  a  case 
of  bilateral  dislocation,  illustrating  hyperextension  of  the  thighs. 

Bilateral  congenital  dislocation  is  treated  in  the  same  manner  as 
the  unilateral.  Both  hips  are  operated  upon  at  one  sitting,  and  are 
fixed  in  the  typical  attitude  (Fig.  421).  Walking  is,  of  course, 
difficult,  but  the  child  is  usually  able  to  stand,  and  after  several 
months  it  is  often  able  to  get  about  on  its  feet  after  a  fashion. 

^Yhen  the  second  spica  is  applied  the  limbs  are  let  down  some- 
what, but  the  degree  depends,  of  course,  on  the  initial  stability. 
The  after-treatment  is  the  same  as  for  the  single  dislocation,  except 
that  the  subsequent  period  of  awkwardness  is  much  longer.  INIassage 
and  exercises  (Fig.  419)  are  far  more  important  than  m  single  dislo- 
cation, as  the  weakness  is  greater.  The  primary  position  during 
sleep  may  be  assured  by  a  cushion  roll  or  wooden  frame  as  used 
bv  Lorenz. 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        549 

The  Treatment  of  Congenital  Dislocation  in  Infancy. — At  the  present 
time  in  contrast  to  former  years  one  often  has  the  opportunity 
to  treat  congenital  dislocation  in  infancy  and  early  childhood.  The 
details  of  treatment  do  not  differ  essentially  from  those  already 
described,  except  that  reduction  is  easily  effected  (Fig.  414)  and 
that  walking  and  weight-bearing,  functional  use  in  other  words, 
cannot  always  be  utilized  at  once  in  the  after-treatment.  In  this 
class  of  cases,  provided  the  test  of  the  stability  of  the  joint  is  satis- 


FiG.  420. — Axillary  abduction. 


factory,  one  need  not  fix  the  limb  in  the  extreme  position.  It  is 
well,  however,  to  carry  the  bandage  below  the  knee  in  order  to  assure 
for  a  time  more  complete  fixation.  The  support  must  be  renewed 
whenever  sanitary  reasons  indicate  the  necessity.  In  many 
instances  cure  is  practically  assured  in  a  few  months. 

Variations  in  the  Treatment. — It  has  been  stated  that  the  first  indi- 
cation of  failure  was  ordinarily  a  slight  lateral  displacement  of  the 
head  to  the  outer  side  of  the  femoral  artery,  and  that  this  displace- 
ment was  favored  by  the  anterior  torsion  of  the  upper  extremity 


550      CONGENITAL   DISLOCATION  OF  HIP  AND   COXA    VARA 

of  the  femur.  As  is  well  known,  anterior  torsion  of  moderate  degree 
is  not  unusual  in  the  femora  of  apparently  normal  joints.  Further- 
more, anterior  torsion  is  always  more  marked  in  early  than  in  later 
life.  According  to  Le  Damany,  at  birth  the  torsion  angle  is  from 
30  to  60  degrees,  from  two  to  four  years  35  degrees,  six  to  twelve 
years  25  to  30  degrees,  in  adult  life  10  to  12  degrees,  and  it  may  not 
therefore  be  a  serious  obstacle  to  successful  treatment  in  early 
childhood.  If,  however,  anterior  torsion  is  suspected  or  is  known 
to  exist,  and  if  displacement  has  recurred  after  the  operation  it  is 
well  to  rotate  the  thigh  inward,  so  that  the  head  of  the  femur  lies 
slightly  to  the  inner  side  of  the  artery,  and  to  fix  it  in  this  attitude 
by  extending  the  plaster  bandage  below  the  knee,  the  leg  being 
slightly  flexed  upon  the  thigh.  This  attitude  should  be  retained 
until  it  may  be  assumed  that  the  capsule  is  sufficiently  contracted 
to  restrain  the  femur  from  reluxation. 

In  some  instances,  especially  in  anterior  displacement  in  young 
subjects,  the  upper  anterior  border  of  the  acetabulum  seems  to 
offer  no  resistance  to  redisplacement.  One  may  then  place  the 
limb  in  axillary  abduction  (Werndorff;  Fig.  420)  for  a  month  or 
more,  in  the  hope  that  the  upper  border  of  the  capsule  will  contract 
sufficiently  to  prevent  redisplacement. 

In  such  cases,  and  in  fact  in  all  cases  in  which  the  upward  dis- 
placement is  feared,  the  patient  should  be  anesthetized  when  the 
plaster  is  changed.  One  may  then  hold  the  head  of  the  femur  in 
place  and  stretch  the  contracted  tissues,  particularly  the  iliofemoral 
ligament,  sufficiently  to  permit  the  lessened  abduction,  for  the  resist- 
ance of  these  tissues  seems  in  certain  instances  to  be  the  direct 
cause  of  displacement. 

The  writer  often  modifies  the  Lorenz  treatment  in  certain  details 
both  in  unilateral  and  bilateral  cases.  In  the  original  attitude  of 
flexion  and  extreme  abduction  the  head  of  the  femur  is  not  within 
the  acetabulum  but  is  pressed  against  the  anterior  wall  of  the  cap- 
sule. This  attitude  is  of  advantage  in  that  it  enlarges  the  capacity 
of  the  joint  anteriorly  and  permits  retraction  of  the  posterior  sac 
which  originally  formed  the  joint.  These  changes  it  may  be  assumed 
have  in  a  young  subject  become  sufficiently  advanced  at  the  end  of 
three  months  to  permit  more  accurate  reposition.  The  patient  is 
again  anesthetized  and  while  by  pressure  on  the  trochanter  the  head 
of  the  bone  is  held  in  its  original  position  the  contraction  of  the 
tissues  that  resist  adduction  is  overcome  and  the  limb  is  rotated 
inward  until  the  patella  points  directly  forward,  a  plaster  support 
is  then  applied  to  fix  the  limb  in  extension  and  in  from  15  to  45 
degrees  of  abduction  according  to  the  stability  of  the  reposition. 
This  support  is  often  extended  to  the  ankle  in  order  to  fix  the  limb 
in  slight  inward  rotation  by  accurate  adjustment  about  the  knee. 
In  this  position  the  head  of  the  femur  is  placed  as  well  as  may  be 
within  the  acetabulum  and  the  weight  of  the  body  in  standmg  and 


Congenital  dislocation  at  the  hip-joint 


551 


walking  is  brought  more  directly  into  use  in  functional  reconstruc- 
tion.    The  second  period  of  fixation  is  for  about  the  same  length 


Fig.  421. — Illustrating  the  range  of  normal  abduction  of  the  thighs,  from  the  atti- 
tude of  right-angular  flexion. 

of  time.     The  procedure  may  be  again  repeated  if  it  seems  desirable, 
the  period  of  retention  being  determined  by  the  original  stability, 


Fig.  422. — The  bandage  applied  after  the  reduction  of  bilateral  dislocation,  showing  a 
favorite  method  of  progression  on  a  chair. 

by  subsequent  tests,  and  by  a>ray  pictures.     In  all  doubtful  cases 
fixation  should  be  prolonged  to  a  period  of  at  least  one  year. 


552       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

There  are  many  variations  of  the  Lorenz  method.  Some  surgeons 
place  the  hmb  primarily  in  extension,  inward  rotation  and  normal 
abduction.  Some  fix  the  limb  for  a  few  months  and  then  employ 
massage.  Others  reduce  the  displacement  by  machines,  which  are 
doubtless  of  advantage  in  resistant  cases,  but  which  are  not  essential 
to  success. 

Prognosis. — ^The  Lorenz  operation  in  older  subjects  is  not  without 
danger.  The  death-rate  attributed  to  anesthesia  is  dispropor- 
tionately large  in  the  cases  reported,  and  in  this  the  violence  of  the 
manipulations  is  undoubtedly  an  important  factor. 

In  450  operations  reported  by  Lorenz  the  following  accidents 
occurred : 

Fracture  of  the  neck  of  the  femur  in 11  cases. 

Fracture  of  the  pelvis  in 3      " 

Peroneal  paralysis  in 3      " 

Crural  paralysis  in 5       " 

Sciatic  paralysis  in 3^     " 

In  the  last  cases  the  paralysis  persisted;  in  the  others  it  was 
temporary.  In  one  case  the  femoral  artery  was  ruptured,  the 
patient  recovering  without  ill-effect.  In  one  case  gangrene  of  the 
extremity  necessitated  amputation  at  the  hip-joint. 

It  may  be  stated,  however,  that  in  the  younger  class  of  cases  the 
operation,  if  conducted  with  reasonable  regard  to  the  resistance  of 
the  tissues  and  to  the  susceptibility  of  the  patient,  is  practically  free 
from  danger. 

In  cases  treated  at  the  proper  age — that  is,  under  six  years 
for  bilateral  and  under  eight  for  unilateral  cases — from  50  to  75 
per  cent,  of  the  unilateral  and  50  per  cent,  of  the  bilateral  cases  can 
be  anatomically  and  functionally  cured,  the  percentage  being,  of 
course,  far  higher  in  the  cases  in  which  at  operation  the  reduction 
is  found  to  be  of  fairly  secure  t^^e.  Nearly  all  the  others  can  be 
greatly  improved,  in  that  the  posterior  displacement  may  be  con- 
verted into  an  anterior  one.  In  such  cases,  in  which  the  head  of  the 
femur  is  forced  forward  below  the  anterosuperior  spine,  the  static 
conditions  become  approximately  normal,  and  further  displacement 
is  to  a  great  extent  prevented  by  the  firm  tissues  attached  at  this 
point.  A  stable  articulation  is  assured  by  long  retention  of  the 
limb  in  the  position  of  abduction  and  extension  by  means  of  the 
plaster  bandage  and  by  exercises  and  passive  movements  after  its 
removal. 

As  has  been  stated,  in  successful  cases  the  head  of  the  femur  can 
always  be  palpated  directly  beneath  the  femoral  artery.     The  first 

1  Eighty-eight  cases  of  paralysis  induced  by  the  operation  have  been  tabulated 
by  Bade,  from  1-3  per  cent,  of  the  cases  reported  by  various  surgeons.  In  16  the 
peroneal  nerve  was  involved,  in  61  the  sciatic  and  in  11  the  paralysis  of  the  limb  was 
complete.  Recovery  is  the  rule  in  from  three  to  eight  months.  Verhandlung  d. 
Gesel.  f.  Orthop.  Chir.,  1909. 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        553 


indication  of  failure  is  a  slight  lateral  displacement  of  the  head  to 
the  outer  side  of  the  artery.  This  may  appear  even  during  the 
period  of  fixation,  and  cases  should  be  systematically  examined  for 
such  failure  by  inserting  the  finger  beneath  the  support;  usually, 
however,  it  is  not  apparent  until  the  plaster  bandage  is  removed. 
At  first  there  is  no  shortening,  but 
as  the  displacement  increases  and  as 
the  head  of  the  bone  ascends  from  the 
neighborhood  of  the  acetabulum  to  a 
position  beside  or  above  the  antero- 
inferior pelvic  spine,  it  becomes  evi- 
dent. At  first  it  is  half  an  inch,  slowly 
increasing  during  growth. 

Lateral  displacement  may  be  ex- 
pected in  about  half  of  the  favorable 
cases  as  to  age  in  which  all  the  details 
of  the  operation  have  been  properly 
carried  out.  This  result,  which  is 
not  classed  by  Lorenz  as  a  failure, 
but  rather  as  an  improvement,  may 
be  explained  in  certain  instances  by 
interposition  of  a  fold  of  capsule  be- 
tween the  head  of  the  bone  and  the 
acetabulum,  or  by  failure  of  the  pro- 
cess of  reformation  of  the  acetabu- 
In  many  cases,  however,  it  is 


mm. 


accounted  for  by  an  anterior  twist  of 
the  upper  extremity  of  the  femur,  so 
that  the  neck  instead  of  pointing  in- 
ward and  slightly  forward  from  the 
shaft  is  turned  forward  and  slightly 
inward.  Thus,  in  order  to  replace  the 
-head  in  the  acetabulum,  the  limb  must 
be  rotated  inward  until  the  foot  points 
inward  rather  than  forward. 

In  most  instances  the  only  remedy 
is  a  cutting  operation.  Lorenz  is  con- 
tent in  these  cases  with  anterior  appo- 
sition, but  if  it  is  probable  that  a  twist 
in  the  upper  extremity  of  the  femur  is 
alone  responsible  for  failure,  it  seems 

more  reasonable  to  remove  this  by  osteotomy  or  increasing  the  re- 
sistance of  the  acetabulum.  This  operation  will  be  described  in 
connection  with  the  open  operation. 

The  Treatment  of  Older  Subjects. — It  has  been  stated  that  the  final 
result  in  a  large  proportion  of  the  cases  beyond  the  age  of  selection 
is  anterior  transposition  or  apposition,  as  Lorenz  calls  it,  and  in 


Fig.  423. — The  cure  of  con- 
genital dislocation.  The  same 
patient  is  shown  in  Fig.  417. 


554       COK GENITAL   DISLOCATION   OF  HIP  AND  COXA   VARA 


cases — from  ten  to  twenty-one  years  of  age — it  may  be  the  primary 
aim  of  the  operation.  After  preHminary  traction  in  bed  and  after 
subcutaneous  division  of  the  more  resistant  tendons  if  necessary,  the 
hmb  is  forced  into  moderate  abduction  and  extreme  extension,  so 
that  the  head  of  the  bone  is  displaced  forward  to  the  neighborhood 
of  the  antero-inferior  spinous  process.     In  this  attitude  the  hmb 


i^ 


Fig.  424. — A  successful  result  after 
the  open  operation,  illustrating  a  form 
of  brace  to  be  used  in  the  after-treat- 
ment to  hold  the  limb  in  proper  posi- 
tion if  it  has  a  tendency  to  rotate  out- 
ward. 


Fig.  425. — Bilateral  dislocation 
six  months  after  replacement  by 
the  open  method  in  1897,  illustra- 
ting the  change  in  the  contour  of 
the  spine. 


is  retained  for  many  months  by  means  of  the  plaster  bandage,  and 
it  is  assured  in  the  after-treatment  by  the  manipulation  and  exercises 
already  described.  Although  even  in  the  most  successful  cases  a 
limp  persists,  yet  it  is  far  less  noticeable  than  in  untreated  cases, 
the  discomfort  is  relieved,  the  limb  is  lengthened,  and  the  danger 
of  future  disability  is  much  lessened. 
In  those  unusual  cases  in  which  the  adduction  and  flexion  de- 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        555 

formity  is  extreme,  osteotomy  of  the  femur  may  be  required,  and  if 
the  pain  is  persistent  excision  of  the  hip  and  implantation  of  the 
shaft  in  the  acetabuhrai  may  be  necessary. 

Arthrotomy. — If  the  Lorenz  operation  has  failed  when  all  the 
details  have  been  thoroughly  carried  out,  the  advisability  of  an 
exploratory  operation  suggests  itself.  Under  proper  aseptic  pre- 
cautions this  should  entail  no  danger  nor  should  it  compromise  the 
functional  ability  of  the  joint.  One  can  then  assure  one's  self  that 
the  head  of  the  bone  is  actually  replaced  within  the  acetabulum. 
Arthrotomy  is  indicated  also  if  the  resistance  to  reposition  by  the 
ordinary  method  is  so  great  that  dangerous  force  must  be  e:  erted 
to  overcome  it. 

The  joint  is  exposed  by  a  lateral  incision  about  three  inches  in 
length,  extending  downward  from  a  point  about  three-quarters  of  an 
inch  to  the  outer  side  of  the  anterosuperior  spine  of  the  ilium,  the 
fascia  is  divided,  and  the  line  of  junction  between  the  tensor  vaginae 
femoris  and  the  gluteus  medius  muscles  is  found.  These  muscles 
are  then  separated  and  are  drawn  to  either  side  by  retractors,  thus 
exposing  the  capsule  of  the  joint.  This  is  opened  by  an  incision 
parallel  to  the  neck  of  the  bone.  The  finger  is  then  passed  through 
the  opening,  down  upon  the  rudimentary  acetabulum.  A  strong 
cervix  dilator  is  next  inserted  .and  the  contracted  capsule  is  thor- 
oughly stretched.     If  the  ligamentum  teres  is  present  it  is  removed. 

The  head  is  then  replaced;  the  capsule  and  overlying  tissues  are 
united  with  catgut  sutures.  The  limb  is  then  fixed  in  the  typical 
position  by  the  Lorenz  spica.  In  the  majority  of  cases  the  cause  of 
the  failure  of  the  primary  operation  is  an  anteversion  of  the  neck  of 
the  femur.  In  this  event  after  replacement  the  limb  must  be 
rotated  inward  to  the  required  degree  and  fixed  by  a  plaster  bandage 
extending  below  the  knee  as  a  preliminary  to  osteotomy. 

Osteotomy. — In  those  cases  in  which  the  anterior  torsion  is  so 
great  that  displacement  must  recur  whenever  the  limb  is  used  in 
the  normal  attitude,  osteotomy  is  indicated.  The  dislocation  is 
first  reduced  by  abduction  and  extreme  inward  rotation  of  the  limb 
and  the  limb  is  fixed  in  this  attitude  for  several  months  until  fair 
stability  is  assured.  The  plaster  support  is  then  removed,  the  limb 
being  held  in  the  attitude  of  inward  rotation  to  prevent  displace- 
ment. 

A  long  drill  fixed  in  a  handle  is  pushed  through  the  shaft  just 
below  the  neck.  A  subcutaneous  osteotome  is  then  inserted  at  a  point 
just  below  the  trochanter  minor  and  a  thorough  division  of  the  bone 
is  made.  When  the  division  is  complete,  the  upper  fragment  being 
fixed  by  holding  the  projecting  drill,  the  limb  is  rotated  outward 
until  the  normal  relation  between  the  shaft  and  the  neck  is  restored. 
A  plaster  spica  including  the  foot  is  then  applied,  the  turns  being 
made  about  the  drill  so  that  outward  rotation  of  the  upper  fragment 
is  prevented.     Several  weeks  later,  when  the  improved  position  is 


556       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

assured,  this  is  withdrawn.  The  after-treatment  is  the  same  as  in 
the  uncompHcated  cases. 

Some  surgeons  perform  the  osteotomy  at  the  lower  third  of  the 
femur  and  postpone  reposition  until  union  is  firm. 

The  Open  Operation  with  Enlargement  of  the  Acetabulum. — The 
original  Hoffa-Lorenz  operation,  once  the  treatment  of  routine, 
is  now  reserved  for  a  restricted  class  of  cases  in  which  the  bloodless 
operation  has  failed,  or  in  wiiich  on  opening  the  joint  the  acetabulum 
is  found  to  be  notablv  deficient. 


■  Fig.  426. — Scoops  used  in  the  treatment  of  congenital  dislocation,  also   the  sub- 
cutaneous osteotome. 

Supposing  the  shortening  of  the  limb  to  have  been  overcome  by 
previous  treatment,  the  joint  and  capsule  are  opened  in  the  manner 
already  described.  One  finger  is  then  inserted  to  the  acetabulum 
and  by  its  side  a  strong,  sharp  bayonet-shaped  spoon  (Fig.  426)  is 
passed,  and  with  it  the  shallow  acetabulum  is  enlarged  to  a  sufficient 
size,  care  being  taken  to  accentuate  its  superior  and  posterior  border. 
The  head  is  then  placed  within  it,  and  the  wound  is  closed.  Hoffa, 
who  was  the  principal  exponent  of  the  operation,  made  an  oblique 
incision  from  the  anterosuperior  spine  downward  and  backward 
over  the  trochanter  and  exposing  the  joint  between  the  gluteus  medius 
and  minimus  muscles.  He  usually  employed  the  Doyen  instrument 
to  bore  out  a  very  capacious  acetabulum  after  reposition.  A  long 
plaster  spica  is  applied  with  the  limb  in  an  attitude  of  moderate 


CONGENITAL  DISLOCATION  AT  THE  HIP- JOINT        557 

abduction  and  extension.  In  a  month,  or  when  repair  is  complete, 
a  short  Lorenz  spica  is  apphed  and  the  patient  is  encouraged  to 
walk  about.     This  support  should  be  worn  for  from  six  months  to  a 


Fig.  427. — Unsuccessful  treatment  by  forcible  correction  (Lorenz  operation).     The 
posterior  has  been  changed  to  an  anterior  displacement.     Rear  view. 

year  in  order  to  prevent  the  contractions  that  almost  inevitably 
follow  operations  of  this  character.  Exercise  and  forcible  manipu- 
lation within  a  few  weeks  after  the  operation,  as  recommended  by 


558       CONGENITAL  DISLOCATION  OF  HIP  AND   COXA    VARA 

many  ^Yriters,  are  not  only  of  no  service,  but  in  the  author's  experi- 
ence, harmful. 

^Yhen  the  spica  is  removed  and  the  child  is  allowed  to  run  about, 
motion  usually  returns.  xA.t  this  time  massage  should  be  employed 
and  passive  movements  always  in  extension  and  abduction.  Later, 
gymnastic  training  is  of  great  value.  After  this  operation,  provided 
there  is  true  anatomical  cure,  motion  is  usually  restricted  to  a  greater 
or  less  degree,  and  in  older  subjects  there  is  often  fibrous  anchylosis. 
For  this  reason  it  should  be  limited  to  unilateral  cases,  or,  at  all 
events,  one  should  never  operate  on  the  second  hip  until  the  result 
of  the  operation  on  the  first  is  known.  In  unilateral  cases  anchylosis 
without  deformity  is  not  a  serious  functional  disability,  as  there  is 
solid  support  without  shortening;  while  if  fair  motion  is  obtained, 
as  in  many  instances,  the  functional  result  is  far  better  than  after 
simple  transposition.  It  should  be  stated  that  even  after  the  open 
operation  there  is  often  lateral  displacement  because  of  the  for- 
ward twist  of  the  femoral  head,  but  not  usually  to  the  point  of 
instability  if  the  acetabulum  has  been  sufficiently  enlarged.  In 
such  cases  motion  is  usually  free  and  the  function  satisfactory.  If 
after  this  operation  motion  is  extremely  limited  one  must  expect 
flexion  and  adduction  deformity  unless  it  be  prevented  by  careful 
treatment.  In  certain  instances  the  range  of  motion  may  be 
increased  by  breaking  up'  adhesions  and  stretching  the  contracted 
parts  under  anesthesia. 

The  danger  of  the  operation  is  slight,  and  the  deaths,  with  but 
few  exceptions,  have  been  due  to  infection.  Lorenz  and  Hoffa  lost 
several  of  their  earlier  patients  from  this  cause,  but  with  improved 
technic  the  danger  is  slight.  The  bad  results  of  the  operation  may, 
as  a  rule,  be  accounted  for  by  its  improper  performance,  particularly 
the  failure  to  replace  the  femur  securely,  or  by  failure  to  ensure 
asepsis,  or  by  inefficient  supervision  and  after-treatment. 

It  is  perhaps  unnecessary  to  state  that  operations  of  this  character 
should  not  be  performed  unless  asepsis  can  be  assured,  unless  the 
operator  is  familiar  with  the  anatomy  of  the  parts,  and  unless  the 
essential  after-treatment  can  be  provided. 

Review  of  the  Treatment  of  Congenital  Dislocation  of  the  Hip. — 
The  prospect  of  success  in  treatment  stands  in  direct  relation  to 
the  age  of  the  patient,  since  the  degree  of  the  pathological  changes 
that  make  cure  difficult  or  impossible  depends,  as  in  acquired  dis- 
locations, upon  the  duration  of  the  disability.  Consequently, 
treatment  should  be  applied  as  soon  as  the  displacement  is  dis- 
covered, and,  as  has  been  stated,  there  is  little  excuse  for  not  making 
the  correct  diagnosis  when  the  child  begins  to  walk.  The  treatment 
of  selection  is  the  functional  weighting  method  of  Lorenz,  modified 
somewhat  in  certain  cases  in  that  the  limb  may  be  placed  with 
advantage  in  that  position  which  best  assures  stability.  In  his 
last  communication,  1909,  from  an  experience  in  more   than  1000 


CONGENITAL  DISLOCATION  AT   THE  HIP-JOINT        559 

cases  Lorenz  states  that  he  has  made  no  essential  change  in  the 
operation.  In  general  he  advises  against  complete  rupture  of  the 
adductors  and  against  forcible  increase  of  the  capacity  of  the  joint 
by  rotation  and  pressure  at  the  time  of  operation.  The  shortest 
period  of  fixation  in  the  primary  position  should  be  six  months, 


^.w- 


^ 


Fig.  428. — Unilateral  dislocation. 
Two  years  after  operation  in  1897  by 
the  Lorenz  method.  A  complete 
cure. 


Fig.  429. — Unilateral  dislocation.  Eigh- 
teen months  after  operation  by  the  Lorenz 
method  in  1897.     A  complete  cure. 


increased  to  8  or  10  in  certain  instances.  By  this  treatment  a 
larger  proportion  of  the  cases  may  be  cured,  and  in  all  instances 
the  posterior  may  be  changed  into  an  anterior  displacement,  which 
is  a  great  improvement.  The  treatment  at  the  hands  of  a  com- 
petent surgeon  in  properly  selected  cases  is  free  from  danger,  for 
now  that  the  strain  that  the  tissues  will  safely  withstand  is  better 


560       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

known,  violent  and  prolonged  manipulation  has  been  discarded. 
In  the  older  class,  or  when  reduction  is  difficult,  the  resistant  parts 
should  be  stretched  by  preliminary  traction  in  bed,  or  the  reduction 
should  be  accomplished  at  two  sittings. 

If  one  is  not  content  with  functional  improvement  in  the  cases 
in  which  anatomical  cure  has  not  been  attained  the  treatment  may 
be  supplemented  by  arthrotomy,  and  if  anteversion  of  the  upper 
extremity  of  the  femur  prevents  success  it  may  be  remedied  by 
osteotomy. 


Fig.  430. — Unilateral  dislocation,  after 
operation  bj-  the  Lorenz  method  in  1897. 
A  complete  cure.    Compare  with  Fig.  402. 


Fig.  431. — Unilateral  dislocation, 
two  years  after  operation.  Compare 
with  Fig.  403. 


Excavation  of  the  acetabulum  will  often  assure  anatomical 
success. 

Anatomical  reposition  with  fair  or  even  very  limited  motion 
assures  better  function  in  unilateral  cases  than  transposition,  but 
anchylosis  with  deformity  is  certainly  no  improvement  on  the 
original  condition.  It  may  be  suggested,  also,  that  the  dangers  of 
open  operation  even  if  slight  must  be  considered. 

In  the  treatment  of  adolescent  cases  one  should  attempt  to  obtain 


SNAPPING  HIP  561 

anterior  transposition  and  to  assure  it  by  fixing  the  limb  for  a 
sufficient  time  in  tlie  improved  position. 

It  should  be  mentioned  that  in  cases  of  congenital  dislocation 
treated  successfully  there  are  changes  preceding  or  subsequent  to 
the  operation  in  the  articulation  which  may  be  classified  as  abnormal 
in  possibly  50  per  cent,  of  the  cases.  The  head  of  the  femur  may  be 
flattened  or  otherwise  distorted.  Its  angle  may  be  diminished 
(coxa  vara)  or  its  forward  inclination  may  be  increased. 

The  acetabulum  may  be  shallow  or  irregular  in  outline. 

The  oapsule  may  be  lax  and  the  head  of  the  femur  may  be 
prominent  in  the  inguinal  region  and  in  some  instances  its  cartilage 
may  be  eroded  from  injury  during  operative  reduction. 

These  so-called  incongruities  may  interfere  with  function  and 
predispose  to  later  changes  resembling  arthritis  deformans  and 
causing  characteristic  symptoms.  As  a  rule,  however,  serious  dis- 
ability from  such  causes  is  unusual. 

Palliative  Treatment. — Palliative  treatment  does  not  require 
extended  comment.  In  brief,  in  unilateral  cases  a  cork  sole  may  be 
worn  to  equalize  the  length  of  the  limbs,  and  in  bilateral  cases  a 
corset  suitably  strengthened  with  steel  supports  may  be  adjusted 
if  the  lordosis  is  extreme.  Exercise  and  passive  manipulation  with 
the  aim  of  retaining,  as  far  as  possible,  the  ability  to  abduct  and 
to  extend  the  thighs  may  be  of  service  in  preventing  secondary 
contractions.  Overexertion  that  causes  discomfort  or  pain  should 
be  avoided. 

CONGENITAL  SUBLUXATION  OF  THE  HIP. 

As  has  been  stated,  there  are  cases  of  congenital  displacement 
of  the  hip  which  are  in  reality  subluxations  and  others  which  pre- 
sent abnormalities  at  the  joint  causing  a  slight  limp  and  slight 
shortening.  In  such  cases  an  a:-ray  picture  may  show  an  enlarged 
acetabulum  somewhat  above  the  plane  of  the  opposite  side,  or  an 
abnormal  laxity  of  the  capsule.  True  subluxations  are  usually  of  the 
anterior  variety.     They  should  be  treated  in  the  ordinary  manner. 

SNAPPING  HIP. 

Some  individuals  possess  the  power  of  slightly  displacing  the 
head  of  the  femur,  usually  upon  the  superior  or  upper  border  of  the 
acetabulum.  This  is  sometimes  seen  in  infancy,  the  child's  thigh 
snapping  with  a  jar  or  even  audible  sound  upward  and  downward. 
This  is  usually  accomplished  when  the  child  is  seated  in  the  mother's 
lap,  the  thigh  being  flexed  and  adducted,  and  in  this  class  of  cases  it 
is,  according  to  the  mothers,  an  evidence  of  temper.  As  a  displace- 
ment may  be  increased  by  habit,  it  is  well  to  restrain  it  by  applying 

1  Brandes:  Ztschr.  f.  orthop.  Chir.,  March,  1915. 
36 


562       COh GENITAL  DISLOCATION  OF  HIP  AND   COXA    VARA 

a  bandage  about  the  hip  to  prevent  flexion  of  the  hmb,  which  is 
apparently  prehminary  to  its  accomphshment.  (See  Snapping 
Knee.)  Snapping  about  the  hip  in  older  subjects  is  usually  induced 
by  friction  between  the  gluteus  maximus  muscle  and  the  trochanter. 
The  limb  flexed  at  the  knee  is  rotated  inward  and  the  tendinous 
attachment  of  the  gluteus  maximus  springs  backward  on  the  tro- 
chanter. It  is  in  a  degree  an  accomplishment  which  is  apparently 
increased  by  practice. 


Fig.  432. — Illustrating    the  Dormal  anatomical  checks  of  abduction    on  the    right 
side  and  the  restriction  of  the  range  caused  by  deformity  on  the  left  side. 


COXA  VARA. 

Synonym. — Depression  of  the  neck  of  the  femur. 

The  character  of  this  deformity  is  indicated  by  the  synonym. 
The  term  coxa  vara  signifies  that  its  causes  and  effects  are  similar 
to  those  of  genu  valgum  and  varum,  the  more  common  distortions 
of  the  lower  extremities. 

Genu  valgum  and  varum  are  common  in  childhood,  but  rarely 
develop  in  adolescence.  Coxa  vara  is,  in  comparison,  an  infrequent 
deformity,  and  it  is  peculiar  in  that  it  more  often  appears  or  attracts 
attention  in  later  childhood  or  adolescence  than  at  the  earlier  period, 
doubtless  because  the  neck  of  the  femur  is,  at  the  age  when  rha- 
chitic  distortions  are  common,  very  short,  and  therefore  relatively 
stronger  than  the  shaft,  while  in  adolescence  the  conditions  may  be 
reversed. 

The  distortions  at  the  knee  are  self-evident,  but  the  neck  of  the 
femur  is  concealed  from  view;  thus  the  diagnosis  of  coxa  vara  may 
be  somewhat  difficult;   and,   in  fact,   it  is  only  in  comparatively 


COXA   VARA 


563 


recent  years  that  its  symptoms  have  been  recognized.  Fiorani^ 
first  described  the  deformity  as  it  had  been  observed  by  him  in 
children;  but  E.  Miiller^  first  called  attention  to  the  affection  as 
one  of  the  deformities  of  adolescence,  which,  until  that  time,  had 
been  mistaken  for  hip  disease 
and  whose  true  nature  was  es- 
tablished by  specimens  obtained 
by  excision. 

Pathology. — The  term  coxa 
vara  should  not  be  applied  to 
depression  of  the  neck  of  the 
femur  that  may  be  secondary 
to  destructive  disease,  for  ex- 
ample, to  osteomyelitis,  arthri- 
tis deformans,  osteomalacia, 
and  the  like,  but  it  should  be 
reserved  for  cases  of  simple 
local  deformity.  In  most  in- 
stances the  deformity  affects 
the  neck  as  a  whole  (cervical 
coxa  vara) ;  in  others  it  is  most 
marked  at  the  epiphyseal  junc- 
tion (epiphyseal  coxa  vara). 
Epiphyseal  coxa  vara  is  more 
often  found  in  the  adolescent 
class,  and  particularly  in  those 
cases  in  which  the  symptoms 
have  been  induced  or  aggra- 
vated by  injury  or  strain. 
Whether  the  injury  caused 
primarily  a  partial  epiphyseal 
separation  which  afterward 
slowly  increased  under  the 
strain  of  functional  use;  or  sud- 
denly  increased   a  preexisting 

distortion  of  the  weakened  part  in  predisposed  subjects  is  sometimes 
difficult  to  decide,  but  in  most  instances  this  type  should  be  classified 
as  a  fracture  rather  than  as  a  developmental  deformity.  A  number 
of  specimens  of  coxa  vara  have  been  examined,  but  no  changes,  other 
than  such  as  might  be  caused  by  the  deformity  itself,  have  been 
found.  These  are,  in  brief,  congestion  and  softening  of  the  bone, 
and  evidences  of  irritation  within  the  joint  during  the  progressive 
stage  of  the  deformity,  together  with  the  general  adaptive  changes 
in  all  the  components  of  the  joint  that  always  accompany  displace- 

1  Gaz.  degli  Ospitale,  1881,  Nos.  16,  17. 

2  Beitr.  z.  klin.  Chir.,  1889,  iv. 

3  Humphrey:  Jour.  Anat.  Phys.,  xxiii,  236. 


Fig.  433. — Section  of  the  upper  ex- 
tremity of  a  normal  femur  at  eight  years 
of  age;  angle  formed  by  the  neck  with  the 
shaft  140  degrees.  In  the  normal  subject 
the  neck  of  the  femur  projects  slightly 
forward  (12  degrees)  and  upward  to  form 
an  angle  with  the  shaft  of  about  125 
degrees.  In  childhood  this  angle  is  usually 
somewhat  greater,  and  in  later  years  it 
may  be  somewhat  less  than  125  degrees; 
in  fact,  a  variation  between  110  and  140 
degrees  may  be  within  the  normal  limit. ' 
Both  anterior  torsion  and  upward  inclina- 
tion are  much  greater  at  birth  than  in  adult 
life.  The  length  of  the  neck  varies  from 
5.9to8.17per  cent. of  thelengthof  the  shaft. 


564      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA 

ment  or  distortion.  These  may  be  considerable,  including,  in  ad- 
vanced cases,  a  change  in  the  acetabulum,  whose  upper  border  is  less 
sharply  defined  than  normal. 

Etiology. — jNIany  writers  assume  that  the  weakness  of  the  neck 
of  the  femur  that  predisposes  to  deformity  is  the  result  of  local 
disease,  such  as  so-called  local  rickets  or  local  osteomalacia.  This 
is,  however,  simply  a  convenient  hypothesis.  Others  believe  the 
deformity  to  be  sjinptomatic  of  late  rickets,  although  evidence  of 
general  rhachitis  is  almost  never  present  in  the  ordinary  type,  as  it 
appears  in  later  childhood  and  adolescence. 

Coxa  vara,  of  the  ordinary  type,  may  be  classed  as  one  of  the 
group  of  static  deformities  of  the  lower  extremity  caused  by  a  dis- 
proportion between  the  strength  of  the  supporting  structure  and  the 
burden  that  is  put  upon  it.  The  support  may  be  disproportionately 
weak,  because  of  inherited  or  acquired  delicacy  of  structure  or  lack 
of  resistance;  it  may  be  weakened  by  injury  or  by  disease,  or  it  may 
be  overburdened  by  weight  or  strain. 

Mechanical  Predisposition  to  Deformity. — In  many  cases  the  pre- 
disposition to  deformity  is  the  result  of  a  lessened  angle  of  the 
femoral  neck.  This  slight  and  predisposing  depression,  which  is  in 
most  instances  the  effect  of  early  rhachitis,  becomes  exaggerated 
to  deformity  during  later  childhood  or  adolescence.  In  this  sense — 
that  of  a  remote  result — coxa  vara  in  adolescence  may  be  classed  as 
one  of  the  rhachitic  deformities.  The  importance  of  this  mechani- 
cal factor  in  the  etiology  was  demonstrated  to  me  by  the  investi- 
gation of  a  number  of  cases  of  simple  fracture  of  the  neck  of  the  femur 
in  childhood.  In  these  cases  the  neck  of  the  femur  was,  by  the 
original  injury,  somewhat  depressed,  and  although  immediate 
functional  recovery  folio-wed,  yet  in  a  number  of  the  cases  progres- 
sive deformity,  attended  by  the  symptoms  of  typical  coxa  ^'ara, 
resulted.  This  could  be  explained  only  on  the  theory  that  the 
lessened  angle,  subjecting  the  part  to  greater  strain,  was  the  predis- 
posing cause  of  the  later  disability.  Other  factors  in  the  etiology 
ma}'  be  general  weakness,  incident  to  rapid  gro^'th,  disordered 
nutrition,  direct  injury  (fracture),  and  the  strain  of  occupation. 

In  this  connection  it  may  be  stated  that  fractiu-e  of  the  neck  of 
the  femur  in  childhood  may  cause  a  deformity  which  in  the  absence 
of  a  history  could  not  be  distinguished  from  the  ordinary  form  of 
coxa  vara,  of  which,  m  fact,  it  is  the  traumatic  form.  At  the  present 
time  in  the  absence  of  immediate  diagnosis  cases  of  fracture  are 
still  classed  as  coxa  vara,  a  very  large  proportion  of  the  unilateral 
cases  being  of  this  character.  If  these  might  be  excluded  coxa  vara 
would  become  one  of  the  deformities  due  in  most  instances  to  the 
immediate  or  remote  effects  of  rhachitis. '^  (See  Fracture  of  the 
Neck  of  the  Femur  and  Epiphyseal  Separation.)  Several  cases  of 
congenital  coxa  vara  have  been  reported.     In  such  instances  the 

1  Wliitman:  Zentralbl.  f.  Chir.,  1910,  No.  11. 


COXA   VARA  565 

deformity  is  often  one  of  many  distortions.  Depression  of  the  neck 
of  the  femur  in  congenital  dislocation  of  the  hip  has  been  mentioned 
in  the  section  on  that  affection. 

If  the  statistics  are  limited  to  the  class  in  which  the  deformity 
causes  the  symptoms  for  which  treatment  is  sought  rather  than  as 
one  of  many  deformities  incidental  to  rhachitis  it  will  appear  very 
decidedly  as  an  affection  of  late  childhood  and  adolescence.  It  is 
far  more  common  in  males  than  in  females  and  it  is  usually  uni- 
lateral, facts  that  indicate  the  influence  of  strain  or  injury  in  induc- 
ing or  inoreasing  the  distortion. 

The  points  of  special  interest  in  72  personal  cases  may  be  sum- 
marized as  follows:  In  about  one-third  of  the  cases  there  was  a 
distinct  history  of  rhachitis  in  infancy.  The  ages  of  the  patients 
were  as  follows: 

Adolescents,  twelve  to  seventeen 40 

Later  childhood,  five  to  eleven 23 

Early  childhood,  less  than  five 3 

Over  seventeen  years 6 

Total • 72 

In  many  instances  the  symptoms  had  persisted  for  a  long  time, 
even  many  years,  before  the  patients  came  under  observation;  but 
taking  this  fact  into  account  it  may  be  stated  that  in  more  than  half 
the  cases  the  deformity  did  not  appear  until  adolescence  and  that 
at  least  three-fourths  of  the  patients  were  beyond  the  period  of 
early  childhood  when  the  ordinary  rhachitic  distortions  of  the  limbs 
are  most  common.  Forty-six  of  the  patients  were  males,  26  were 
females.  In  59  cases  the  deformity  was  unilateral,  32  of  the  right 
and  27  of  the  left  side;  in  13  it  was  bilateral.  In  the  majority  of  the 
cases  the  neck  of  the  femur  was  distorted  in  a  direction  backward 
and  downward;  in  perhaps  10  either  directly  downward  or  down- 
ward and  forward.  Many  of  the  patients  were  observed  before  the 
ir-rays  were  available  for  diagnosis,  but  it  is  estimated  that  in  about 
one-fourth  of  the  adolescent  cases  the  distortion  was  greatest  in  the 
vicinity  of  the  head  of  the  bone  (epiphyseal  coxa  vara) ;  in  the  others 
the  neck  of  the  femur  as  a  whole  was  involved  (cervical  coxa  vara) . 

Symptoms. — 1.  Mechanical  Effects. — The  character  of  the  symp- 
toms may  be  explained  by  a  description  of  the  distortion  and  of 
its  direct  effects  upon  the  function  of  the  joint.  When  the  neck 
of  the  femur  is  depressed,  for  example,  to  a  right  angle  with  the 
shaft,  the  trochanter  is  elevated  to  a  corresponding  degree  above 
Nelaton's  line,^  and  forms  a  noticeable  projection  as  contrasted  with 

1  Nelaton's  line  (Element  de  Path.  Chir.,  Paris,  1847) :  Patient  lies  upon  the  side  4 
with  the  limb  flexed  to  90  degrees,  and  slightly  adducted.  In  this  attitude  a  line 
drawn  from  the  anterosuperior  spin*  to  the  most  prominent  part  of  the  tuberosity 
of  the  ischium  passes  across  the  tip  of  the  trochanter  and  approximately  the  centre 
of  the  acetabulum.  According  to  Preiser  (Berlin,  1911)  the  trochanter  is  usually/ 
slightly  above  the  line  (40  per  cent,  on  the  line).  In  extreme  adduction  it  is  abouy 
3  cm.  below,  and  in  extreme  abduction  6  cm.  above  the  line.  In  the  extreme  of 
extension  the  trochanter  is  below,  in  flexion  above  the  line.  In  inward  rotation 
below,  and  in  outward  rotation  above  the  line. 


566      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

the  normal  contour  (Fig.  437),  a  projection  that  becomes  more 
marked  when  the  thigh  is  flexed  and  adducted  (Fig.  436).  In  most 
instances  the  neck  is  twisted  backward  following  the  line  of  least 
resistance  in  its  downward  course,  and  as  the  head  of  the  bone 
remains  in  the  acetabulum  the  trochanter  is  thrown  forward  and  the 
limb  is  rotated  outward.  The  ability  to  abduct  the  thigh  is  depend- 
ent upon  the  upward  inclination  of  the  femoral  neck  (Fig.  441); 
when,  therefore,  this  inclination  is  diminished  the  range  of  abduc- 
tion is  lessened,  in  part  by  the  greater  tension  that  is  exerted  upon 
the  lower  portion  of  the  capsule,  in  part  by  the  direct  contact  of  the 
rim  of  the  acetabulum  with  the  neck  (Fig.  434),  and  in  part  by  the 


Fig.  43-4. — Skiagram  of  coxa  ^'ara ;  deforinit j'  most  marked  at  the  epiphj'seal 
junction.  This  ilhistrates  the  mechanical  limitation  of  abduction  caused  by  the 
deformitj',  and  the  compensatory  tilting  of  the  pelvis.  The  patient  is  shown  in 
Fig.  437. 


adaptive  muscular  retractions  that  alwaj's  accompany  distortions 
of  this  character.  The  distortion  of  the  neck  in  a  direction  back- 
ward and  downward  changes  the  relation  of  the  acetabulum  to  the 
head  of  the  femur,  so  that  abduction  or  flexion  tends  to  displace  it 
from  its  socket.  Thus  the  range  of  abduction,  of  inward  rotation, 
and  of  flexion  is  limited,  while  that  of  adduction,  outward 
rotation,  and  extension  may  be  increased. 

There  is  actual  shortening  of  the  limb  dependent  upon  the  upAvard 
displacement  of  the  shaft  of  the  femur.  This  is  not  often  more  than 
an  inch  in  the  ordinary  type  of  adolescent  deformity,  but  the  appar- 
ent shortening,  caused  by  the  adduction  and  the  accommodative 


COXA   VARA  56? 

upward  tilting  of  the  pelvis,  may  be  extreme;  from  two  to  three 
inches  is  not  uncommon  (Fig.  437) . 

2.  Physical  Effects. — The  symptoms  of  coxa  vara  of  the  ordinary 
type  are  discomfort,  awkwardness,  limp,  shortening,  atrophy,  limita- 
tion of  motion,  deformity. 

Coxa  vara  is  a  more  disabling  deformity  than  genu  varum  or 
valgum,  and  its  attendant  symptoms  of  discomfort,  weakness,  and 
pain  are,  as  a  rule,  more  marked.  This  is  explained  by  the  fact 
that  in  coxa  vara  the  head  of  the  bone  is  in  part  displaced  from  the 
acetabulum  (Fig.  435),  while  in  the  deformities  at  the  knee  the  joint 
surfaces  remain  in  practically  normal  relation  to  one  another. 

The  symptoms  of  unilateral  coxa  vara  vary  with  the  degree  and 
with  the  duration  of  the  deformity.  The  patient  usually  complains 
of  sensations  of  stiffness  and  weakness,  referred  to  the  thigh. 
These  are  more  noticeable  on  changing  from  a  position  of  rest  to 
one  of  activity,  and  at  times,  particularly  after  overexertion,  there 
may  be  actual  pain.  By  far  the  most  important  symptom  and  the 
one  that  almost  always  induces  the  patient  to  seek  treatment  is  the 
limp.  This  limp,  accompanied,  as  it  usually  is,  by  outward  rotation 
of  the  limb,  resembles  that  caused  by  united  fracture  of  the  neck 
of  the  femur.  On  physical  examination  the  actual  shortening, 
explained  by  the  elevated  and  prominent  trochanter  and  the  pecu- 
liar unequal  limitation  of  motion,  will  make  the  diagnosis  clear.  In 
some  instances  there  may  be  a  marked  degree  of  muscular  spasm, 
and  there  is  usually  moderate  atrophy  of  the  muscles  of  the  thigh. 

Bilateral  Coxa  Vara. — If  the  deformity  is  bilateral  its  effect  upon 
the  gait  and  attitude  is  more  marked.  The  gait  is  extremely 
awkward,  resembling  somewhat  that  of  knock-knees,  for  the  limita- 
tion of  abduction  forces  the  patient  to  sway  the  body  from  side  to 
side  in  order  that  the  knees  may  not  interfere;  and  if  the  deformity 
is  extreme  the  limbs  may  be  crossed  over  one  another,  so  that  loco- 
motion may  be  difficult.  In  the  ordinary  form  of  bilateral  coxa 
vara  femoral  neck  on  each  side  is  displaced  backward  as  well  as 
downward,  and  as  the  head  of  the  femur  remains  in  the  acetabulum 
the  shaft  is  thrown  forward,  so  that  the  trochanter  is  nearer  the 
anterosuperior  spine  than  is  normal.  This  displacement  of  the 
support  lessens  the  inclination  of  the  pelvis  and  consequently  the 
normal  lumbar  lordosis.  Bilateral  coxa  vara  is  not  infrequently 
accompanied  by  other  deformities,  as,  for  example,  knock-knee  or 
flat-foot  (Fig.  438),  and  it  is  usually  an  indirect  result  of  former 
rhachitis  or  of  constitutional  weakness  while  in  unilateral  coxa  vara 
injury  (fracture)  is  the  most  frequent  cause. 

..Other  Varieties  of  Coxa  Vara. — ^Far  less  often  the  neck  of  the  femur 
may  be  depressed  directly  downward  or  even  downward  and  for- 
ward. In  the  latter  instance  the  effect  of  the  deformity  upon  the 
function  of  the  joint  is  somewhat  different  from  that  of  the  ordi- 
nary type.     Abduction  is  limited,  as  in  the  common  form,   but 


568       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

inward  rotation  replaces  outward  rotation,  and  extension  is  limited 
in  place  of  flexion.  This  type  of  deformity  is  almost  always 
bilateral.  It  is  accompanied,  usually,  by  slight  permanent  flexion 
of  the  thighs;  thus  the  lumbar  lordosis  is  exaggerated;  whereas 
in  the  ordinary  form  it  is  usually  lessened. 

This  description  applies  to  the  ordinary  types  of  the  deformity 
as  it  is  seen  in  later  childhood  and  in  adolescence.  It  it  not  uncom- 
mon in  early  life  as  one  of  the  rhachitic  deformities  but  it  is  masked 
by  the  more  noticeable  distortions  of  other  parts  (see  Fig.  386).  It 
is  usually  bilateral  and  it  may  be  suspected  whenever  abduction  is 
markedly  limited.    This  form  is  rarely  presented  for  treatment  but 


Fig.  435. — Cross-section  of  the  pelvis  and  the  deformed  femur.  A  scheme  to  show 
the  effect  of  the  deformity  in  limiting  abduction  of  the  limb.  The  dotted  outline 
shows  the  normal  relation. 


it  is  important  as  a  predisposing  cause  of  the  progressive  deformity 
of  later  years.  In  some  cases  of  the  rhachitic  type,  however,  the 
deformity  may  cause  discomfort  and  awkwardness  during  the  earlier 
years,  the  disability  becoming  more  noticeable  in  later  childhood, 
indicating  a  continuity  of  symptoms. 

In  the  majority  of  cases  of  the  ordinary  t;ype  the  symptoms  begin 
insidiously,  in  the  unilateral  form  often  as  the  result  of  injury  or 
overexertion.  (See  Partial  Epiphyseal  Separation.)  If  the  affection 
begins  in  adolescence  and  is  untreated,  the  period  of  discomfort, 
during  which  the  depression  of  the  neck  may  be  assumed  to  be 
progressive,  is  from  two  to  four  years;  but  if  the  deformity  appears 


COXA    VARA 


569 


at  an  early  age,  the  symptoms,  though  remittent  in  character,  may 
continue  indefinitely.  When  the  resistance  of  the  compressed  bone 
becomes  sufficient  to  ensure  stability  the  discomfort  ceases,  and 
the  disability  becomes  less  marked,  as 
nature  accommodates  the  mechanism  to 
the  new  conditions. 


Fig.  436. — Coxa  vara,  showing  the  prominent 
trochanter. 


Fig.  437.— Illustrating 
the  tilting  of  the  pelvis 
and  the  apparent  shorten- 
ing of  the  limb  in  unilateral 
coxa  vara.  Actual  shorten- 
ing, three-fourths  of  an 
inch;  apparent  shortening, 
two  and  a  half  inches.  The 
deformity  of  the  epiphyseal 
type  was  apparently  in- 
duced by  overexertion. 
(See   skiagram,    Fig.    434.) 


Diagnosis. — In  most  instances  diagnosis  may  be  easily  made, 
and  yet  coxa  vara  is  very  often  mistaken  for  hip  disease;  in  fact, 
we  are  indebted  to  this  mistake  for  the  specimens  of  the  deformity 
that  have  been  described.  The  essential  differences  between  the 
two  are  as  follows:  In  tuberculous  disease  of  the  hip  the  motions 
of  the  joint  are  limited  in  every  direction  by  reflex  muscular  spasm, 
and,  as  a  rule,  other  evidences  of  the  character  of  the  disease  are 


570      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA 

apparent.  Coxa  vara  is  a  simple  deformity;  reflex  muscular 
spasm  is  absent,  except  during  exacerbations  due  to  injury  or  over- 
strain, and  movement  is  not  limited  in  all  directions,  but  only  in 
abduction,  flexion,  and  inward  rotation  when  the  deformity  is  of  the 
ordinary  type.  Actual  shortening  is  a  late  symptom  of  hip  disease, 
while  it  is  present  from  the  very  onset  of  coxa  vara.  It  is  a  short- 
ening explained  by  the  elevation  of  the  trochanter  above  Nekton's 
line,  while  such  elevation  in  hip  disease  is  a  sign  of  destruction  either 
of  the  head  of  the  bone  or  of  a  part  of  the  acetabulum. 

The  deformity  in  young  subjects  might  be  readily  mistaken  for 
congenital  dislocation  of  the  hip,  particularly  of  the  anterior  variety, 
but  this  would  be  excluded  by  the  history,  since  coxa  vara  is  essen- 


FiG.  4S8. — Double  coxa  vara  of  advanced  degree,  showing  the  involuntary  crossing 
of  the  limbs  in  flexion  which  increases  the  adduction. 

tially  an  acquired  deformity.  The  diagnosis  between  the  two 
affections  may  be  easily  made  on  the  physical  signs  alone.  In  con- 
genital dislocation,  if  the  thigh  be  flexed  and  adducted  to  its  extreme 
limit,  the  head  and  neck  of  the  displaced  bone  can  be  outlined 
beneath  the  distended  tissues  of  the  buttock.  In  coxa  vara  nothing 
but  the  prominent  trochanter  can  be  made  out  on  similar  manipu- 
lation, while  the  abnormal  mobility,  characteristic  of  the  dislocation, 
is  absent.  There  is,  however,  a  form  of  anterior  dislocation  in 
which  the  head  of  the  femur  has  a  secure  support  beneath  the 
anterosuperior  spine  in  which  diagnosis  from  the  physical  signs 
alone  may  be  somewhat  more  difficult.  An  a:;-ray  picture  will 
always  make  the  distinction  clear,  however. 


COXA    VARA 


571 


Treatment. — If  the  deformity  were  discovered  in  the  early  stage, 
one  might  hope  to  check  its  progress  by  an  avoidance  of  the  exciting 
causes.  For  example,  long  standing  or  work  of  any  kind  |that 
induces  the  familiar  symptoms  of  strain  should  be  discontinued. 
As  much  time  as  possible  should  be 
spent  in  the  open  air,  and  diet  and 
proper  remedies  should  be  employed 
if  evidence  of  constitutional  weak- 
ness or  rhachitis  is  present  as  in 
early  childhood. 

Locally,  massage  of  the  limbs  and 


Fig.  439. — Unilateral  coxa  vara,  showing 
the  effect  of  slight  depression  of  the  neck  of 
the  left  femur  upon  the  attitude.  (See  Fig. 
440.) 


Fig.  440. — The  patient,  Fig. 
439,  eight  months  after  cuneiform 
osteotomy.  An  absolute  cure, 
both  as  regards  symptoms  and 
deformity. 


joints  and  forcible  manipulation,  with  the  aim  of  overcoming  as 
much  of  the  restriction  of  the  range  of  abduction  as  may  depend 
upon  the  secondary  changes  in  the  soft  parts,  should  be  employed, 
reinforced  by  regular  gymnastic  exercises,  with  the  object  of  im- 
proving the  circulation,  upon  which  the  repair  of  the  weakened  bone 
depends. 


572      CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 

If  the  affection  is  unilateral  and  progressive,  with  but  slight 
deformity  a  perineal  crutch  (Fig.  303)  or,  if  the  circumstances  of 
the  patient  permit,  one  of  the  convalescent  hip  splints  that  per- 
mits motion  at  the  knee,  may  be  used  (Fig.  305).  With  support 
durmg  the  time  of  greatest  strain — that  is,  when  continuous  walkmg 
or  standing  may  be  acquired — combined  with  proper  exercises  and 
massage,  the  weak  part  may  become  sufficiently  strong  to  perform 
its  function  in  a  year  or  more,  but  supervision  will  be  necessary  for 
a  much  longer  time. 

Operative  Treatment. — As  a  rule  operative  correction  of  the 
deformity  is  indicated. 

Forcible  Abduction. — ^In  certain  instances,  particularly  those  cases 
in  adolescence  in  which  the  symptoms  ha^'e  advanced  rapidly,  it 
may  be  inferred  that  the  bony  structure  of  the  affected  neck  is  con- 
gested and  softened.  And  durmg  the  active  stage  of  rhachitis  in 
early  childhood  the  neck  of  the  femur  may  be  sufficiently  yielding 
to  permit  a  certain  degree  of  correction  by  forcible  abduction  of 
the  femur.  In  this  maneuvre  the  head  is  fixed  by  the  lower  por- 
tion of  the  capsule,  and  the  deformed  neck  is  forced  against  the 
upper  border  of  the  acetabulum  as  illustrated  in  the  diagrams 
(Fig.  4A2).  If  the  normal  range  of  abduction  and  inward  rotation 
can  be  restored,  one  may  infer  that  the  deformity  has  been  corrected. 
The  limb  should  then  be  fixed  by  a  plaster  spica  bandage  in  this 
attitude  of  extreme  abduction  and  inward  rotation  until  consolida- 
tion in  the  new  position  is  apparently  complete.  A  short  spica  to 
hold  the  limb  in  abduction  should  then  be  applied  and  continued 
for  several  months.     (See  Epiphyseal  Fractures.) 

A  support  should  be  used  for  a  time,  and  the  usual  treatment  by 
massage  and  exercise  should  be  carried  out  until  voluntary  and 
passive  motion  is  relatively  free.  In  early  childhood  the  deformity 
is  usually  bilateral  and  both  are  treated  simultaneously. 

Linear  Osteotomy. — The  most  efficient  means  of  overcoming  the 
deformity  in  older  subjects  m  which  extreme  outward  rotation 
indicates  backward  distortion  of  the  neck  is  linear  osteotomy  of  the 
shaft  of  the  femm-  just  below  the  trochanter  minor.  This  may  be 
performed  by  the  subcutaneous  method,  as  in  the  correction  of  the 
deformity  of  hip  disease.  ^Mren  the  bone  has  been  divided  the  shaft 
is  rotated  inward  to  the  proper  degree,  and  it  is  then  under  traction 
abducted  to  the  normal  limit;  in  this  attitude  a  plaster  spica  ban- 
dage is  applied  reaching  from  the  axilla  to  the  toes. 

If  the  deformity  is  bilateral  it  is  often  sufficient  to  operate  on  the 
limb  which  is  most  affected.  ^Mien  the  fracture  is  consolidated, 
massage,  exercises,  and  manipulation  are  employed,  as  has  been 
described.  It  may  be  assumed  that  the  increased  blood  supply 
necessitated  by  the  repair  of  the  injury  will  affect  fa^'orab]y  the 
weakened  bone  as  well. 


COXA    VARA 


573 


Cuneiform  Osteotomy. — If  outward  rotation  is  not  marked  the 
deformity  should  be  remedied  by  removal  of  a  cuneiform  section 
of  bone  from  the  upper  extremity  of  the  shaft  at  the  level  of  the 
trochanter  minor  (Fig.  441).  In  childhood  the  neck  of  the  femur 
is  short  and  the  strain  to  which  it  is  likely  to  be  subjected  slight; 
thus  operative  treatment  may  be  indicated  as  a  prophylactic 
measure.  In  fact,  one  should  treat  this  deformity  at  the  hip  on  the 
same  principles  as  the  similar  distortions  at  the  knee.  Coxa  vara 
cannot  be  rectified  by  mechanical  treatment;  therefore,  unless  it  is 
directly  contra-indicated,  operative  intervention  should  be  advised. 


Fig.  441. — 1,  the  normal  femur;  2,  depression  of  the  neck  of  the  femur — coxa 
vara;  A,  a  wedge  of  bone  has  been  removed;  3,  abduction  of  the  limb  first  fixes  the 
upper  segment  by  contact  with  the  rim  of  the  acetabulum,  then  closes  the  opening 
in  the  bone;  4,  replacement  of  the  limb  after  union  is  completed  elevates  the  neck 
to  its  former  position. 

In  the  technic  of  this  procedure  there  are  several  points  of  impor- 
tance. First,  the  restriction  of  abduction,  of  ligamentous  or  mus- 
cular origin,  must  be  overcome  by  vigorous  stretching  and  massage 
of  the  shortened  tissues  before  the  operation  on  the  bone.  An 
incision  is  made  from  a  point  about  one  inch  below  the  apex  of  the 
trochanter  directly  downward  about  three  inches  in  length.  The 
bone  is  thoroughly  exposed  by  separating  the  periosteum  from  the 
site  of  operation.  The  base  of  the  wedge  should  be  about  three 
quarters  of  an  inch  in  breadth,  directly  opposite  the  trochanter 
minor;  the  upper  section  should  be  practically  at  a  right  angle  with 
the  shaft,  the  lower  being  more  oblique  (Fig.  433,  2) .     The  situation 


574       COXGEXITAL  DISLOCATION   OF  HIP  AND   COXA    VARA 

and  size  of  the  wedge-shaped  resection  necessary  to  restore  the  nor- 
mal angle  of  the  neck  may  be  determined  by  making  a  paper  model 
from  an  .r-ray  picture.  The  cortical  substance  on  the  inner  aspect 
of  the  bone  should  not  be  divided,  but,  reinforced  by  the  cartilagi- 
nous trochanter  minor,  should  serve  as  a  hinge  on  which  the  shaft 
of  the  femur  is  gently  forced  outward,  until  the  opening  is  closed 
by  the  apposition  of  the  fragments  after  the  upper  segment  has  been 
fixed  by  contact  with  the  margin  of  the  acetabulum  (Fig.  441,  3); 
thus  the  continuity  of  the  bone  is  preserved.  The  limb  is  then 
fixed  in  the  attitude  of  normal  abduction  by  means  of  a  plaster 
spica  bandage,  which  should  include  the  foot  also,  for  about  eight 
weeks,  or  until  the  union  is  firm.  When  the  limb  is  brought  to 
the  line  of  the  body  the  neck  of  the  femur  is  restored  to  its  proper 
position  (Fig.  441,  4)-  This  mechanical  method  of  apposing  the 
fragments  is  absolutely  effective.  This  method  in  which  the  exact 
section  of  bone  required  to  correct  the  deformity  may  be  determined 
by  an  .r-ray  picture  and  in  which  the  continuity  of  the  bone  is 
preserved  has  a  manifest  advantage  over  a  simple  osteotomy  in 
which  there  is  danger  of  displacement  of  the  fragments.  In  ordinary 
cases  of  this  class,  according  to  the  writer's  experience,  the  cure  is 
absolute,  both  as  to  symptoms  and  to  function. 

The  opportunity  for  treatment  of  coxa  vara  in  earliest  child- 
hood is  rarely  offered.  It  is  usually  the  direct  result  of  rhachitis 
and  it  is  probably  always  accompanied  by  other  rhachitic  distortions. 
It  would  be  well,  therefore,  to  examine  the  hip-joints  of  rhachitic 
children,  especially  those  who  present  the  deformity  of  genu  valgum 
with  reference  to  this  distortion. 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 

"Traumatic  Coxa  Vara." — Fracture  of  the  neck  of  the  femur  in 
childhood,  although  until  recently  unrecognized,  is  by  no  means 
uncommon.  A  large  number  of  cases  have  come  under  my  obser- 
vation since  1890,  when  attention  was  first  called  to  the  subject.^ 
It  is  seen  in  two  forms.  In  the  first  the  fractm-e  is  of  the  neck  and  it 
usually  follows  direct  violence.  In  the  second  the  fracture  is  at  the 
epiphyseal  junction  with  the  head.  This  form  is  practically  limited 
to  adolescence. 

Simple  Fracture. — Fracture  of  the  neck  of  the  femur  in  childhood 
differs  somewhat  in  its  s\Tiiptoms  and  in  its  eftects  from  that  in  later 
life.  Although  it  may  be  complete,  it  is  often  what  may  be  termed 
the  "green  stick"  variety.  Thus,  the  immediate  effects  of  the 
injury  are  far  less  disabling,  and  the  patient  is  often  able  to  walk 
about  within  a  few  days  or  weeks  after  the  accident.  During  the 
period  of  repair  the  limp  and  attendant  discomfort  are  usually 

'  New  York  Med.  Jour.,  February  7,  1891 ;  Xew  York  Med.  Rec,  Fel^ruary  2.5,  1893. 


SIMPLE  FRACTURE 


575 


mistaken  for  symptoms  of  hip  disease  and  at  a  later  time  it  is  classed 
as  coxa  vara. 

Diagnosis. — ^The  diagnosis  is  not  difficult  even  without  .T-ray 
examination.  There  is  a  history  of  injury,  usually  a  fall  from  a  height 
which  confined  the  patient  to  the  bed  for  several  days  or  weeks. 
On  physical  examination  shortening  of  half  an  inch  to  an  inch  is 
found,  explained  by  the  corresponding  elevation  of  the  trochanter. 
Motion  in  the  joint  is  more  or  less  restrained  by  voluntary  and  invol- 
untarv  contraction  of  the  muscles,  but  this  restriction  is  much  more 


Fig.  442. — 1,  fracture  of  the  neck  of  the  femur;  2,  restoration  of  the  normal 
angle  by  forcible  abduction;  3,  the  Hmb  in  normal  .position;  ^.,  5,  and  6  illustrate 
separation  of  the  epiphysis  of  the  head  of  the  femur  treated  by  the  same  method. 


marked  in  flexion,  abduction,  and  inward  rotation  than  in  other 
directions;  a  limitation  explained  by  the  nature  of  the  displace- 
ment, the  neck  of  the  bone  having  been  forced  downward  and 
backward. 

The  immediate  effect  of  the  injury  is,  as  has  been  stated,  less 
marked  than  in  the  adult,  but  the  deformity  tends  to  increase  in 
later  years,  because  the  right-angled  relation  of  the  neck  to  the 
shaft  exposes  it  to  greater  strain.  In  a  number  of  the  patients 
examined  several  years  after  the  injury  there  was  an  increase  of  the 
actual  shortening  combined  with  permanent  adduction.  At  this 
time  the  deformity  could  not  have  been  distinguished,  except  for 
the  history,  from  the  ordinary  coxa  vara  of  a  rather  extreme  degree. 


576       CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA 


Treatment. — If  the  diagnosis  is  made  immediately  or  before  con- 
solidation is  complete,  one  should  attempt  to  replace  the  neck  in 
its  proper  relation  with  the  shaft  in  order  to  restore  normal  function 
and  to  prevent  subsequent  disability.  The  patient  having  been 
anesthetized,  the  limb,  under  manual  traction,  should  by  gentle 
force  be  rotated  inward  and  then  gradually  abducted,  the  upper 
border  of  the  acetabulum  serving  as  a  fulcrum  for  leverage  by  means 

of  which  even  resistant  deformity  may  be 
corrected.  In  this  position  of  complete 
abduction  and  extension  a  plaster  spica, 
reaching  from  the  axilla  to  the  toes,  should 
be  applied  (Fig.  442).  The  abduction 
treatment  for  this  class  of  cures  was  first 
described  in  the  Annals  of  Surgery,  June, 
1897.  After  consolidation  of  the  fracture 
a  Lorenz  spica  may  be  used  for  several 
months  or  until  complete  repair  has 
taken  place.  Massage  and  passive  move- 
ments, if  limitation  of  motion  persists, 
should  restore  function  if  the  deformity 
has  been  overcome. 

The  deformity  of  untreated  and  con- 
solidated fracture  is  practically  a  form 
of  coxa  vara.  In  such  cases  the  neck 
of  the  femur  should  be  replaced  in  its 
normal  position  by  the  removal  of  a  suffi- 
cient wedge  of  bone  from  the  base  of  the 
trochanter  as  described  under  the  treat- 
ment of  simple  coxa  vara  (Fig.  441). 

Epiphyseal  Fracture.  —  As  has  been 
stated,  in  early  life  the  fracture  is  usually 
at  the  base  of  the  neck,  which  in  child- 
hood is  but  little  more  than  an  inch  in 
length.  In  later  years  the  head  of  the 
femur  may  be  partially  or  completely 
separated  at  or  near  the  epiphyseal  line. 
This  disjunction  is  more  common  in  ado- 
lescence and  particularly  in  fat,  overgrown 
or  weak  subjects,  although  it  may  occur 
in  perfectly  healthy  individuals.  Thus  sudden  disability,  following 
slight  injury,  in  an  adolescent  who  has  complained  of  discomfort  and 
limp  for  some  time  before,  should  suggest  this  accident,  the  previous 
sjTiiptoms  being  explained  by  slight  displacement  or  weakening  of 
the  epiphyseal  junction.  In  other  instances  the  separation  may  be 
complete,  the  direct  result  of  violence  (Fig.  443) . 

Treatment. — In  characteristic  cases  the  limb  is  adducted,  usually 
extended,  rotated  outward  to  an  extreme  degree,  and  often  prac- 


FiG.  443. — Epiphyseal 
fractiire  of  the  neck  of  the 
right  femur,  illustrating  the 
tjTDe  of  patient  especially 
predisposed  to  such  injury 
and  the  characteristic  atti- 
tude of  the  limb. 


SIMPLE  FRACTURE  577 

tically  fixed,  by  muscular  spasm.  If  the  separation  is  complete  a 
prominence  may  be  felt  below  and  to  the  inner  side  of  the  antero- 
superior  spine  representing  the  inner  extremity  of  the  neck  which 
lies  above  and  in  front  of  the  head. 

If  the  fracture  is  recent  the  deformity  may  be  reduced  by  forcible 
•manipulation  under  anesthesia,  the  order  being  flexion  and  inward 
rotation,  followed  by  traction  and  abduction  or  in  recent  cases  by 
direct  abduction.  In  many  instances,  however,  the  injury  is  of  long 
standing  and  the  fragments  are  so  interlocked  and  adherent  that 
they  cannot  be  disengaged.  In  such  cases  open  operation  is  indi- 
cated. An  incision  about  five  inches  in  length  is  made  downward 
from  the  anterosuperior  spine  along  the  outer  or  inner  side  of  the 
tensor  vaginse  femoris  muscle.  The  joint  is  opened  and  the  surface 
of  the  neck  is  at  once  exposed,  completely  concealing  the  head. 
By  extreme  outward  rotation  of  the  limb  this  may  be  brought  into 
view  and  a  thin  chisel  is  inserted  between  the  two.  The  fragments 
are  then  forced  apart  and  by  traction  and  internal  rotation  the  neck 
is  gradually  brought  into  its  proper  relation.  In  many  instances, 
however,  a  thin  section  of  bone  must  be  removed  from  the  extremity 
of  the  neck  to  permit  reduction  without  violence.  The  wound  is 
closed  and  a  long  spica  plaster  is  applied  to  hold  the  limb  in  exten- 
sion, inward  rotation  and  abduction  until  union  is  firm.  Active 
and  passive  exercises  should  be  employed  until  function  is  restored.^ 

As  has  been  suggested,  slight  injury,  under  favoring  conditions, 
may  rupture  the  periosteum  and  the  cortical  substance  at  the  junc- 
tion of  the  epiphysis  and  the  neck  of  the  femur,  and  under  the  strain 
of  use  the  head  of  the  bone  may  be  slowly  depressed,  the  final  result 
being  the  epiphyseal  type  of  coxa  vara  that  has  been  described,  in 
which  repair  and  deformity  are  coincident.  The  symptoms  of  this 
variety,  which  is  practically  limited  to  adolescence,  resemble  those 
of  ordinary  coxa  vara,  except  that  they  are  more  marked  and  more 
disabling. 

Fracture  of  the  Neck  of  the  Femur  in  Adult  Life. — Seven  cases 
of  ununited  fracture  of  the  neck  of  the  femur  in  early  life  have  come 
under  my  observation,  all  of  the  patients  having  been  treated  by 
routine  methods,  proving  that  non-union  after  this  injury  is  not  to 
be  accounted  for  by  deficiency  of  blood  supply  but  by  inefficient 
treatment.  This  indicates  that  if  in  the  adult  class  deformity 
were  reduced  and  the  injured  part  supported,  repair  and  restoration 
of  function  might  result  in  a  large  proportion  of  the  cases. 

The  treatment  by  abduction  and  fixation  recommended  for  frac- 
ture of  the  neck  of  the  femur  or  epiphyseal  separation  in  childhood, 
with  the  aim  of  restoring  symmetry,  should  be  applied  therefore  in 
all  cases  that  are  amenable  to  treatment.  The  so-called  impacted 
fracture  if  caused  by  indirect  violence  is  in  most  instances  incom- 

1  Whitman:  New  York  Med.  Rec,  January,  1909. 
37 


o^; 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA 


plete  rather  than  impacted  in  the  sense  of  actual  penetration  of  one 
fragment  into  the  other,  and  if  the  deformity  is  not  corrected,  func- 
tional disability  is  inevitable. 

The  Abduction  Treatment.- — The  patient  having  been  anesthetized 
is  placed  upon  the  back,  the  shoulders  and  head  supported  by  a  box 
of  sufRcient  size,  about  seven  inches  in  height,  the  pelvis  resting  on  a 
sacral  support,  pro\'ided  preferably  with  a  perineal  bar  for  fixation  of 


Fig.  444. — The  range  of  normal  ab- 
duction limited  by  contact  of  bone  and 
by  tension  on  the  capsule. 


Fig.  445. — Fracture  and  displacement. 


Fig.  446. — Reduction  by  the  abduction  method. 


the  trunk,  both  extended  limbs  beng  held  by  assistants.  That  on  the 
sound  side  is  then  abducted  to  the  normal  limit  to  demonstrate  the 
normal  range  and  to  fix  the  pelvis.  That  on  the  injured  side  is  then 
under  traction  slowly  abducted  and  rotated  inward,  the  surgeon 
supporting  the  joint  with  his  hands  and  pressing  the  trochanter 
gently  downward.  The  limitation  of  abduction,  caused  by  contact 
of  the  deformed  neck  with  the  upper  border  of  the  acetabulum,  is 
recognized,  but  it  is  easily  overcome.     ^Yhen  the  limit  of  normal 


SIMPLE  FRACTURE 


579 


abduction  is  reached  it  may  be  inferred  that  the  proper  relation 
between  the  neck  and  shaft  of  the  femur  has  been  restored.     The 


Fig.  447. — The  abduction  treatment  of  fracture  of  the  neck  of  the  right  femur, 
illustrating  the  reduction  of  the  deformity  by  direct  traction  and  abduction.  The 
operator  supports  the  joint.  The  left  limb  is  abducted  to  indicate  the  normal  range, 
which  varies  in  different  subjects,  and  to  prevent  tilting  of  the  pelvis. 


Fig.  448. — Fixing:;  the  liml)  in  complete  abduction  and  extension. 


hmb  in  this  attitude  of  complete  extension,  abduction  and  slight 
inward   rotation   is    then   securely  fixed  by   a  long  plaster  spica 


580      COXGEXITAL   DISLOCATIOX  OF  HIP  AXD   COXA    VARA 

(Fig.  4-4S).  It  may  be  noted  that  this  method  of  reducing  the 
deformity  by  abduction  followed  by  the  immediate  application  of 
support  hardly  corresponds  to  what  is  kno'«^l  as  the  "breaking  up 
of  an  impaction."  Far  from  endangering  union  it  should  favor  it 
by  actually  apposing  the  fractured  surface. 

If  the  fractiue  is  complete  the  same  treatment  is  adopted  with 
the  following  modification.  The  patient  lying  in  the  position 
described,  the  disabled  member  is  first  flexed  to  disengage  folds  of 


Fig, 


449. — A  caliper  traction  hip  brace  that  may  be  used  with  advantage  in  the 
after-treatment  to  permit  locomotion  without  direct  weight-bearing. 


capsule  that  may  have  fallen  between  the  fragments.  It  is  then 
extended  and  rotated  inward  to  the  normal  attitude  and  under 
traction  and  counter-traction  the  shortening  is  completely  over- 
come, as  demonstrated  by  measurement.  The  sound  Imib  is  then 
abducted  to  the  limit  to  demonstrate  the  normal  individual  range 
and  to  fix  the  pelvis.  The  limb  on  the  injured  side  is  then  slowly 
abducted  by  the  assistant  while  the  surgeon  supporting  the  joint 
pushes  the  thigh  upward  from  beneath  to  force  the  two  fragments 
against  the  anterior  part  of  the  capsule.     When  the  limit  of  abduc- 


SIMPLE  FRACTURE  581 

tlon  has  been  reached  the  capsule  will  be  tense,  thus  directing  the 
fragments,  now  in  a  horizontal  plane  and  end  to  end,  toward  one 
another  and  finally  forcing  the  contact.  If  the  fracture  is  near  the 
head,  the  outer  fragment  may  be  inserted  beneath  the  acetabular  rim. 
_  If  at  the  base,  the  trochanter  under  ordinary  conditions  will  be  apposed 
to  the  side  of  the  pelvis,  thus  preventing  upward  displacement. 
Furthermore,  the  muscles  whose  contraction  favors  deformity,  will 
be  completely  relaxed,  or  so  changed  in  direction  that  displacement 
from  this  source  is  impossible.  The  fracture  is  as  if  it  were  locked 
by  internal  splinting  and  it  is  only  necessary  to  hold  the  limb  in  the 
attitude  of  complete  abduction  and  complete  hyperextension  by  a 
plaster  spica.  This,  being  an  independent  splint,  permits  frequent 
changes  of  attitude,  even  turning  the  patient  to  the  ventral  atti- 
tude to  rest  the  back.  In  the  treatment  of  elderly  subjects  it  is 
well  to  raise  the  head  of  the  bed  from  1  to  2  feet  to  lessen  the 
danger  of  hypostatic  congestion  of  the  lungs  and  to  increase  the 
blood  supply  at  the  seat  of  injury.  Repau*  is  very  slow  and  weight 
must  not  be  borne  for  many  months.  In  the  after-treatment  the 
support  of  a  modified  hip  splint  (Fig.  449)  is  desirable,  and 
functional  recovery  will  be  hastened  by  massage  and  by  appro- 
priate active  and  passive  exercises  of  which  by  far  the  most 
important  is  to  draw  the  limb  at  intervals  to  the  complete  limit 
of  abduction. 

One^  often  encounters  cases  in  which  the  disability  from  fracture 
of  the  neck  of  the  femur  persists  even  though  union  has  taken  place. 
This  is  due  in  great  part  to  adduction,  which  is  induced  primarily 
by  depression  of  the  neck  of  the  femur  and  by  fixation  of  the  limb 
in  the  line  of  the  body  as  in  conventional  treatment.  That  part  of 
the  deformity  due  to  muscular  retraction  may  be  overcome  by  force 
under  anesthesia.  The  limb  is  then  fixed  for  a  time  in  the  degree 
of  abduction  that  the  deformity  permits.  If,  as  is  often  the  case, 
the  fracture  has  failed  to  unite  and  the  open  operation  is  imprac- 
ticable the  upper  extremity  of  the  femur  may  be  forced  forward 
beneath  the  anterosuperior  spine  and  the  limb  may  be  fixed  in  an 
attitude  of  abduction  and  extension  by  a  short  spica,  as  originally 
suggested  by  Lorenz. 

Open  Operation. — In  those  cases  of  ununited  fracture  in  young 
or  middle-aged  subjects  in  which  non-union  may  be  explained  by 
failure  to  appose  the  fragments  the  open  operation  may  be  indicated. 

The  shortening  having  been  reduced  by  preliminary  traction  in 
bed  an  incision  is  made  from  the  anterosuperior  spine  downward 
and  outward  to  the  base  of  the  trochanter,  between  the  tensor  vagin?e 
femoris  and  gluteus  medius  muscles.  The  joint  is  opened  in  the 
line  of  the  neck,  the  fibrous  tissue  is  removed  from  the  surfaces  of 
the  fragment,  and  they  are  further  modified  to  assure  apposition. 

1  The  latest  of  the  author's  papers  on  the  subject  may  be  found  in  the  Annals  of 
Surgery  for  August,  1914. 


582     CONGEXITAL  DISLOCATIOX  OF  HIP  AND  COXA   VARA 

A  long,  strong  bone  drill  is  then  tlu'iist  through  the  skin,  the 
trochanter,  and  the  neck  initil  its  point  emerges.  The  fractured 
surface  of  the  neck  is  then  apposed  to  the  head  and  the  drill  is 
driven  deeply  into  its  substance.  In  place  of  the  drill  a  bone  peg 
from  the  crest  of  the  tibia  or  from  the  fibula  should  be  used  if  the 
nutrition  is  impaired.  The  wound  is  closed  and  the  limb  is  fixed 
in  an  attitude  of  extension  and  abduction  by  a  plaster  spica.  The 
after-treatment  is  similar  to  that  for  non-operative  cases.  In 
hopeless  cases  the  head  should  be  removed  from  the  acetabulum, 
the  trochanter  removed  and  displaced  downward  on  the  shaft  and 
the  remaining  portion  of  the  neck  implanted  in  the  acetabulum. 

Fracture  of  the  Thigh  in  Infants. — Obstetrical  fractures  of  the  thigh 
are  sometimes  seen  in  orthopedic  clinics.  These  are  most  effec- 
tively treated  by  flexing  the  extended  limb  upon  the  trunk  and  bind- 
ing the  femur  and  abdomen  in  contact,  thus  preventing  the  anterior 
angulation  that  characterizes  the  fracture.^ 

COXA  VALGA. 

Coxa  valga  is  a  term  used  to  signify  an  abnormal  elevation  of  the 
neck  of  the  femur  in  its  relation  to  the  shaft,  in  contrast  to  coxa 
vara,  an  abnormal  depression.  It  is  usually  congenital.  It  is 
sometimes  observed  in  limbs  which  have  never  supported  weight, 
and  it  is  a  possible  result  of  injury  also.  Its  s^Tiiptoms  are  an  awk- 
ward gait,  the  limb  being  rotated  outward  and  abducted.  The 
deformity  is  very  uncommon  and  is  of  slight  importance.  Sixteen 
cases  have  been  collected  by  ]Maullaire  and  Oliver.- 

Treatment  should  be  directed  to  overcoming  the  limitation  of 
adduction.  This  may  be  manipulative  or  by  force  under  anesthesia 
followed  by  retention  in  the  attitude  of  adduction.  In  rare  instances 
osteotomy  may  be  indicated.^ 

1  Zancarini:  Milnchen.  med.  Wchnschr.,  November  16,  Ivi. 

-  Arch.  gen.  de  chir.,  iv,  15,  1. 

3  Young:  Univ.   Pa.   Bull.,   January,    1907. 


CHAPTER    XVI. 

DEFORMITIES  OF  THE  BONES  OF  THE  LOWER 
EXTREMITY. 

Of  the  distortions  of  the  lower  extremity  bow-leg  and  knock- 
knee  are  by  far  the  most  common,  comprising  about  15  per  cent, 
of  the  total  cases  in  orthopedic  clinics.  Of  the  two,  bow-leg  is  the 
more  frequent  in  all  tables  of  statistics,  and  it  is  probable  that  the 
proportion  of  bow-leg  to  knock-knee  is  much  larger  than  would 
appear  from  the  hospital  records;  for  genu  valgum  is  generally 
recognized  as  a  serious  deformity,  while  bow-leg  is  thought  to  be  of 
little  consequence  except  from  the  esthetic  stand-point,  so  that  its 
rectification  is  more  often  trusted  to  the  power  of  nature. 

Both  deformities  appear  to  be  more  common  in  male  than  in 
female  children — a  fact  explained,  perhaps,  by  the  greater  weight 
and  the  greater  susceptibility  of  the  former.  But  here,  again,  statis- 
tics may  be  influenced  somewhat  by  the  fact  that  bow-leg  is  con- 
sidered to  be  of  more  consequence  to  the  boy  than  to  the  girl, 
because  of  the  concealment  that  the  skirts  will  ensure  if  the  distor- 
tion is  not  outgrown  in  childhood. 

Statistics. — The  relative  frequency  of  the  two  deformities  may 
be  indicated  by  the  statistics  of  the  Hospital  for  Ruptured  and 
Crippled  for  a  period  of  fifteen  years.  During  this  time  8760  cases 
were  recorded,  5741  cases  of  bow-leg  (65.5  per  cent.),  3019  knock- 
knee  (34.5  per  cent.).  Of  the  5741  cases  of  bow-leg  3401  were  in 
males  (59  per  cent.)  and  2340  were  in  females  (41  per  cent.).  The 
3019  cases  of  knock-knee  were  more  evenly  divided  between  the 
sexes,  1610  being  in  males  (50.04  per  cent.)  and  1409  in  females 
(49.06  per  cent.). 

It  will  be  noted  that  94  of  the  cases  of  knock-knee  were  in  patients 
over  fourteen  years  of  age,  as  compared  with  78  cases  of  adolescent 
or  adult  bow-leg.  The  writer's  personal  experience  in  the  clinic 
enables  him  to  state  that  a  large  proportion  of  the  cases  of  genu 
valgum  actually  developed  or  increased  to  an  extent  demanding 
treatment  during  adolescence,  while  most  of  the  cases  of  bow-leg 
deformity  in  patients  more  than  fourteen  years  of  age  had  existed 
since  early  childhood  or  were  the  result  of  injury  or  disease. 

The  Etiology  of  Genu  Valgum,  Genu  Varum,  and  of  Other 
Distortions  of  the  Bones  of  the  Lower  Extremity. — The  common 
predisposing  cause  of  simple  deformities  and  disabilities  of  the 
lower  extremities — in  other  words,  those  not  caused  by  local  disease 


584      DEFORMITIES  OF  BOXES  OF  LOWER  EXTREMITY 

— is  the  erect  posture,  when  for  any  reason  the  bones  and  the  joints 
are  unequal  to  the  strain  of  locomotion  and  to  the  task  of  sustain- 
ing the  weight  of  the  body. 

Time  of  Onset. — At  two  periods  of  life  the  deformities  under  con- 
sideration most  often  develop.  The  first  is  in  early  childhood, 
when  the  upright  posture  is  first  assumed;  the  second  is  m  adoles- 
cence, when  the  rapid  growth  and  other  changes  mcident  to  this 
period  may  lessen  the  stability  of  the  supporting  structures,  and 
when  the  strain  of  laborious  occupation  may  be  added  to  that  of  the 
mcreasing  weight  of  the  body. 

The  deformities  of  adolescence  are,  however,  relatively  insignifi- 
cant in  number  compared  with  those  of  early  childhood,  for  in  child- 
hood inherited  weakness  or  weakness  that  is  the  direct  result  of 
malnutrition  at  once  develops  into  deformity  under  the  stram  of 
standmg  and  walking.  Thus,  as  a  rule,  the  deformities  under  con- 
sideration first  attract  attention  soon  after  the  child  begins  to  walk. 
If  the  deformities  are  severe  the  body  usually  presents  the  evidences 
of  general  rhachitis;  in  other  instances  the  distortion  of  the  legs  is 
almost  the  only  sign  of  its  presence,  and  in  a  certain  number  there 
may  be  no  evidence  whatever  of  malnutrition  or  disease. 

Predisposition  to  Deformity. — It  is  not  always  easy  to  explam  why 
weak  legs  bend  in  one  way  rather  than  m  another.  In  many 
instances  it  may  be  assumed  that  a  slight  degree  of  deformity  is 
present  before  the  child  begms  to  walk.  For  example,  a  slight  out- 
ward bowmg  of  the  legs  is  not  uncommon  in  early  infancy,  and  the 
use  of  heavy  diapers  might '  favor  an  increase  of  the  distortion. 
Ivnock-knee  may  be  induced,  apparently,  by  holding  the  infant  on 
the  arm  with  the  knees  pressed  agamst  the  chest,  and  certam  cases 
of  knock-knee  and  bow-leg  combmed  appear  to  be  caused  directly 
by  this  manner  of  carrying  the  infant  habitually  upon  one  arm. 

The  legs  of  rhachitic  children  who  may  have  never  walked  are 
often  somewhat  distorted  and  in  many  instances  this  may  be 
explained  by  the  habitual  postures  (Fig.  450). 

A  moderate  degree  of  bow-leg  is  not  infrequently  seen  m  vigorous 
infants  who  stand  and  walk  at  an  early  age.  Aside  from  the  deter- 
mining curve  in  the  bone  that  may  be  present  before  the  child 
begins  to  walk,  this  predisposition  toward  bow-leg  may  be  explained, 
perhaps,  by  the  fact  that  young  infants  often  separate  the  feet 
widely  in  walkmg,  and  the  swaying  of  the  body  from  side  to  side 
may  tend  to  bend  the  legs  outward.  In  weaker  or  less  vigorous 
children  a  slight  degree  of  knock-knee  is  not  uncommon,  induced 
more  directly  by  weakness  or  inactivity  of  the  muscles,  as  a  result 
of  which  the  child  stands  with  the  knees  somewhat  flexed  and 
pressed  together,  while  the  feet  are  separated  and  everted,  an  exag- 
geration of  the  so-called  attitude  of  rest. 

Bow-leg  is  not  uncommon  m  adult  life,  and  it  is  popularly  associ- 
ated with   strength  and   activit^^     Undoubtedlv  the  attitudes  of 


ETIOLOGY  OF  GENU   VALGUM  AND  GENU   VARUM      585 

activity  would  tend  to  induce  bow-leg  rather  than  knock-knee,  so 
that  this  tradition  may  have  a  foundation  of  truth.  It  is  said  to  be 
common  among  those  who  ride  constantly,  and  it  may  be  a  direct 
result  of  injury  or  disease  of  the  knee-joint,  but  it  may  be  stated  that 
well-marked  bow-leg  in  an  adult  has  almost  always  existed  since 
childhood.  This  statement  cannot  be  made  of  genu  valgum,  since 
it  may  develop  or  increase  during  adolescence  or  even  in  adult  life. 
The  predisposing  cause  is  weakness  or  overstrain,  and,  as  has  been 
stated,  in  the  popular  mind  the  deformity  is  characteristic  of 
weakness. 


Fig.  450. — Habitual  posture  as  a  factor  in  the  etiology  of  rhachitic  bow-leg.    '^^ 

The  Attitude  of  Rest. — Genu  valgum  is  an  exaggeration  of  what  is 
known  as  the  attitude  of  rest  or  relaxation,  in  which  the  weight  of 
the  body  is  thrown  in  great  part  upon  the  ligaments  of  the  three 
joints  of  the  lower  extremity.  In  the  attitude  of  rest  the  pelvis  is 
tilted  forward,  the  femora  are  rotated  inward  upon  the  tibise,  and 
the  feet  are  separated  and  everted,  so  that  the  greatest  strain  falls 
upon  the  inner  side  of  the  knees  and  of  the  feet.  Thus,  what  is 
known  as  flat-foot  is  in  childhood  often  combined  with  knock-knee. 
Knock-knee  may  cause  flat-foot,  but  more  often  the  flat-foot  may 
induce  knock-knee,  or  both  may  be  the  effect  of  the  same  general 


586       DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 

cause.  Genu  valgum,  in  the  slighter  degree  at  least,  may  be  induced 
directly  by  improper  attitudes;  but  the  attitudes  are,  as  a  rule,  the 
result  of  overwork  to  which  the  mechanism  is  subjected;  thus  the 
knock-knee  of  adolescence  is  so  common  among  the  bakers  of 
Vienna  that  "baker's  knee"  is  there  synonymous  with  genu  valgum. 

Genu  valgimi  may  be  secondary  to  distortion  elsewhere.  For 
example,  compensatory  knock-knee  is  usually  combined  with  fixed 
adduction  of  the  thigh;  it  may  be  the  result  of  the  inactivity  neces- 
sitated by  the  treatment  of  hip  disease;  it  may  be  a  direct  result 
of  injury,  and  it  is  sometimes  an  accompaniment  of  osteomyelitis 
or  osteoperiostitis  of  the  tibia,  which  causes  an  overgrowth  and 
abnormal  lengthening  of  the  leg.  These  are,  however,  exceptional 
cases  that  should  no:  be  classed  with  the  ordmary  deformity. 

The  Outgrowth  of  Deformity. — ^In  considering  the  treatment  of  the 
simple  static  deformities  of  the  lower  extremity,  which  are  usually 
the  result  of  a  temporary  weakness  of  structure,  one  must  first 
answer  the  question,  "Will  not  the  child  outgrow  it?"  This  belief 
in  the  spontaneous  cure  of  deformity  is  very  strong,  not  only  among 
the  laity,  but  among  physicians  as  well;  and  it  rests  upon  the  com- 
mon observation  that  crooked  legs  may  become  straight,  or  at  least 
less  deformed,  with  the  gro'^'th  of  the  child.  In  fact,  if  one  were  to 
judge  from  the  general  observation  of  the  effect  of  growth  upon  the 
deformities  of  this  class,  or  even  from  the  tracings  of  the  legs  of 
rhachitic  children  taken  from  year  to  year,  one  might  conclude  that 
all  deformities  of  this  class  might  be  safely  left  to  themselves.  As 
an  illustration  of  positive  evidence  on  the  subject,  the  observations 
of  Kamps^  on  32  cases  of  rhachitic  distortion  of  the  lower  extremity 
may  be  cited.  Four  and  one-half  years  after  the  cases  were  first 
seen  and  recorded  examination  showed  that  75  per  cent,  were  cured, 
15.3  per  cent,  improved,  while  9.7  per  cent,  were  unimproved.  His 
conclusions  are  that  such  deformities  do  not,  as  a  rule,  require 
special  treatment  in  early  childhood,  but  that  after  the  age  of  six 
years  the  prognosis  for  spontaneous  cure  is  unfavorable. 

Yeit^  photographed  a  number  of  rhachitic  children  seen  in  the 
surgical  clinic  of  the  University  of  Berlm,  and  after  a  lapse  of  two  or 
three  years  made  another  series  of  photographs  of  the  same  patients, 
who  had  meanwhile  received  no  treatment.  His  conclusions  are 
similar  to  those  of  Kamps,  namely,  that  surgical  treatment  is  not 
required  for  deformity  of  this  character  in  children  less  than  six 
years  of  age.  In  two  classes  of  cases,  however,  the  prognosis  for 
spontaneous  cure  is  not  favorable,  those  in  which  the  growth  has 
been  checked  bv  the  rhachitic  process,  and  in  certain  cases  of  extreme 
bow-leg,  "O"  legs  (Fig.  451). 

The  rectifying  force  of  nature  acts  in  two  ways.  Assuming  that 
the  deformity  reached  its  limit  during  the  period  of  original  weak- 

1  Beitr.  z.  klin.  Chir.,  Band  xiv,  Heft  1.  =  Arch.  f.  Cliir.,  B.  1,  S.  130. 


ETIOLOGY  OF  GENU   VALGUM  AND  GENU  VARUM      587 


ness,  it  must,  of  course,  become  relatively  less  as  the  body  increases 
in  length  and  size.  In  fact,  the  outgrowth  of  deformity  has  a  direct 
relation  to  the  rapidity  of  growth  during  the  early  years  of  child- 
hood. It  must  be  borne  in  mind  also  that  not  infrequently  rhachitic 
bones  are  bent  in  two  or  more  directions,  so  that  knock-knee  and  bow- 
leg may  be  combined  in  the  same  person.  Thus  the  bow-leg  may 
be  outgrown  while  the  knock-knee  persists  or  even  becomes  less 
noticeable.  The  second  manifestation  of  the  power  of  nature  is 
more  positive.  It  may  be  assumed  that  when  the  deformity  is 
progressi've  all  the  tissues  are  affected  by  the  weakness;  consequently 
the  attitudes  of  the  child  are  those  that  can  be  most  easily  assumed 
under  the  abnormal  conditions. 
But  when  the  primary  cause  of 
the  weakness,  in  most  instances 
rhachitis,  is  no  longer  operative, 
the  muscles  take  on  new  activity 
and  vigor,  and  the  actions  and 
attitudes,  in  spite  of  the  deform- 
ity, become  approximately  nor- 
mal. Then,  according  to  Wolff's 
lawof  transformation,  the  internal 
structure  of  the  affected  bones 
begins  to  change  in  accommoda- 
tion to  the  new  conditions  of 
weight  and  strain  induced  by 
the  change  in  action  and  atti- 
tude; and  to  this  rearrangement 
of  the  internal  structure  the  ex- 
ternal shape  of  the  bones  must 
conform  in  a  gradual  growth 
toward  the  normal  contour. 

On  this  theory  it  is  easily  ex- 
plained how  the  natural  outdoor 
life  of  the  country  has  long  been 
celebrated  as  an  effective  treat- 
ment for  this  class  of  deformity. 

that  deformity  is  always  outgrown  even  under  favorable  conditions. 
Improper  attitudes  that  favor  and  cause  deformity  are  often 
observed  among  those  who  are  free  from  weakness  and  disability 
and  from  the  influences  of  unfavorable  surroundings;  and  such 
attitudes  are,  of  course,  more  likely  to  persist  in  those  who  were 
once  obliged  to  assume  them  because  of  weakness  and  deformity. 
Again  the  weakness  of  structure  or  function  may  be  an  inherited 
peculiarity,  or  it  may  be  induced  by  disease  or  by  improper  sur- 
roundings, influences  that  may  continue  for  many  years  and  thus 
serve  to  check  the  natural  tendency  toward  cure. 

The  observations  on  the  outgrowth  of  deformity  have  been  con- 


FiG.  451. — ^A  type  of  deformity  in 
which  the  prognosis  as  regards  out- 
growth is  bad. 


It  by  no  means  follows,  however. 


58S       DEFORMITIES  OF  BOXES  OF  LOWER  EXTREMITY 


fined,  as  a  rule,  to  the  period  of  childhood,  and  most  often  they  have 
been  made  with  reference  to  the  more  serious  grades  of  distortion, 
which  are  the  direct  result  of  rhachitis.  It  must  be  borne  in  mind, 
however,  that  the  true  significance  of  these  deformities  in  the  adult 
must  be  judged  from  the  esthetic  rather  than  from  the  medical 
point  of  view,  and  although  the  extreme  degrees  of  bow-leg  and 
knock-knee  are  relatively  rare,  yet  in  the  minor  grade  both  deformi- 
ties are  very  common  in  adult  males  and  in  all  probability  in  adult 
females  also. 


Fig.  452.- 


-Extreme  deformities,  the  result  of  infantUe  rhachitis.     The  left  leg  forms 
practically  a  right  angle  -nith  the  thigh.      (See  Fig.  4.56.  j 


In  1887  the  writer^  noted  among  2000  adult  males  observed  on 
the  streets  of  Boston  400  cases  of  bow-leg  and  32  cases  of  knock- 
knee.  One  may  assiune,  then,  that  the  legs  of  about  one  adult  male 
in  five  deviate  more  or  less  from  the  line  of  symmetry — a  conclusion 
that  has  been  confirmed  by  many  subsequent  observations.  It  may 
be  admitted  that  a  certain  number  of  the  distortions  under  con- 
sideration are  acquired  during  adolescence,  but  it  is  probable  that 


1  New  York  Med.  Rec,  July  30,  1887. 


GENU   VALGUM 


589 


the  greater  number  of  those  that  may  be  noted  in  walkers  upon 
the  streets  represent  the  incomplete  outgrowth  of  a  deformity  of 
childhood. 

The  statement  is  often  made  that  these  distortions  of  the  legs  are 
common  in  childhood,  but  rare  in  adult  life.  Just  what  the  pro- 
portion may  be  in  childhood  it  is  impossible  to  say,  but  it  is  not 
likely  to  be  greater  than  one  in  five.  One  must  conclude  that  statis- 
tics, on  which  such  statements  are  based,  have  been  made  up  from 
the  records  of  hospitals  where  it  is  unusual  for  an  adult  to  apply 
for  the  treatment  of  bow-leg,  to  which  he  has  become  accustomed 
since  childhood,  unless  the  deformity  is  extreme  or  causes  dis- 
comfort. 

Granting  that  the  power  of  nature  is  quite  sufficient  to  modify 
or  to  cure  even  the  more  extreme  distortions  of  childhood,  still  it 
is  evident  that  this  natural  force  is  often  ineffective  in  completing 
the  cure.  Therefore,  in  doubtful  cases  at  least,  one  should  lend 
assistance  in  that  class  of  patients  likely  to  appreciate  the  advantage 
of  symmetry  over  deformity,  even  though  it  be  unattended  by  dis- 
comfort or  disabilitv. 


Fig.  453.— Female.  Fig.  454.— Male 

Figs.  453  and  454. — The  normal  inclination  of  the  femora.      (Pfeiffer.) 


GENU  VALGUM. 

Synonyms. — Knock-knee,  in-knee. 

In  the  erect  posture  the  thighs,  whose  upper  extremities  are 
separated  by  the  pelvis  and  by  the  projecting  femoral  necks,  incline 
slightly  inward  to  the  knees,  forming  an  angle  at  the  knee,  opening 
outward,  of  about  172  degrees.  This  angle  varies  with  the  breadth 
of  the  pelvis,  and  it  is  therefore  less  in  adult  females  than  in  males 
(Figs.  453  and  454).  The  internal  condyle  of  the  femur  is  slightly 
longer  than  the  external;  thus  the  inclination  of  the  femur  is  com- 
pensated and  the  plane  of  the  knee-joint  is  horizontal. 


590       DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 

Symptoms. — ^Ylle^  the  inward  projection  of  the  knees  is  increased 
to  a  noticeable  degree  the  tibia  are  no  longer  perpendicular;  their 
upper  extremities  incline  inward  so  that  in  the  erect  posture  the  feet 
are  separated  when  the  knees  are  in  contact  (Fig.  4.55).  In  the 
slighter  grades  of  knock-knee,  which  are  due  in  great  degree  to  laxity 
of  the  ligaments,  the  deformity  is  apparent  only  when  the  weight 
of  the  body  is  borne,  but  in  more  marked  cases,  although  the  dis- 
tortion is  increased  by  the  weight  of  the  body,  it  cannot  be  overcome 
when  this  is  removed,  because  it  depends  upon  actual  changes  in 
the  shape  of  the  bones  themselves. 


Fig.  4.55. — Adolescent  knock-knee. 


Deformity  most   marked  in  the   tibiae.      (See 
Fig.  459.) 


As  has  been  stated,  the  normal  inward  inclination  of  the  femur 
is  compensated  by  the  greater  length  of  the  internal  condyle,  and 
in  the  deformity  of  knock-knee  the  plane  of  the  knee-joint  is  still 
preserved  by  an  apparent  elongation  of  the  inner  condyle.  Formerly 
it  was  supposed  that  there  was  an  actual  overgro^^"th  of  this  part 
of  the  epiphysis  which  caused  the  deformity,  but  this  apparent 
lengthening  is  in  reality  due  in  great  part  to  a  deformity  of  the  lower 


GENU   VALGUM  591 

extremity  of  the  shaft  of  the  femur,  which  is  so  bent  that  the  epi- 
physeal hne  has  an  increased  obhquity.  And  the  hypothesis  that 
bone  grows  more  rapidly  when  relieved  from  weight  and  strain  has 
been  disproved  by  Wolff,  who  has  demonstrated  that  changes  in 
the  bones  are  the  result  of  accommodation  to  altered  function  and 
attitude.  The  deformity  is  not  limited  to  the  femur;  in  most 
instances  there  is  a  similar,  although  usually  slighter,  irregularity 
in  the  epiphyseal  line  of  the  upper  extremity  of  the  tibia,  the  shaft 
being  so  bent  that  when  it  is  placed  in  the  perpendicular  position 
its  internal  condylar  surface  is  higher  than  the  external.  In  some 
instances  the  primary  and  principal  deformity  is  of  the  shaft  of 
the  tibia,  the  distortion  being  most  marked  in  its  upper  third  (Fig. 
455). 

Changed  Relation  of  the  Femur  and  Tibia. — In  addition  to  the 
direct  deformities  of  the  bones  there  is  a  change  in  the  relation 
of  the  femur  to  the  tibia.  The  former  is  rotated  inward  and  the 
latter  is  rotated  outward.  In  some  instances  there  is  also  a  certain 
degree  of  overextension  at  the  knee.  This  is  more  often  observed 
in  the  adolescent  type,  in  which  there  is  laxity  of  the  ligaments 
(Fig.  455).  In  the  ordinary  form  of  rhachitic  knock-knee  in  child- 
hood the  habitual  attitude  is  one  of  slight  flexion  at  the  knees,  and 
in  extreme  cases  there  may  be  actual  limitation  of  the  range  of  exten- 
sion at  the  knee,  and  at  the  hip  as  well. 

The  Accommodative  Attitude. — When  the  limb  is  fully  extended 
the  deformity  is  most  marked,  because  the  shortened  ligaments  and 
tissues  on  the  outer  aspect  of  the  joint  become  tense,  and  because 
the  outward  rotation  of  the  tibia  is  increased.  As  the  leg  is  flexed 
the  deformity  lessens,  and  in  the  attitude  of  complete  flexion  it 
disappears  (Fig.  459).  This  is  explained  by  the  fact  that  the  pos- 
terior surface  of  the  condyles  is  not  affected  by  the  deformity  of  the 
shaft,  while  the  relaxation  of  the  ligaments  and  the  outward  rota- 
tion of  the  femora  allow  the  tibise  to  become  parallel  with  one 
another.  This  accounts  for  the  habitual  attitude  of  slight  flexion 
which  is  so  often  assumed  by  patients  who  thus  unconsciously 
accommodate  themselves  to  the  deformity. 

Secondary  Deformities. — The  outward  inclination  of  the  leg  throws 
more  weight  upon  the  inner  border  of  the  foot  and  tends  to  depress 
it  into  the  attitude  of  valgus.  Thus  knock-knee  in  weak  children 
is  often  accompanied  by  flat-foot,  but  in  the  more  extreme  grades  of 
deformity  the  efforts  of  the  patient  to  compensate  for  the  abnormal 
separation  of  the  feet  may  result  in  habitual  inversion  (Fig.  455) ; 
in  fact,  confirmed  and  extreme  knock-knee  in  older  subjects  is  usually 
accompanied  by  a  slight  degree  of  varus  that  become  very  evident 
after  the  correction  of  the  deformity  by  operation.  Even  in  the 
mildest  type  of  knock-knee  this  compensatory  and  conservative 
effort  of  nature  is  shown  by  the  so-called  pigeon-toed  walk,  which 
is  often  the  first  symptom  that  attracts  attention. 


592      DEFORMITIES  OF  BONES  OF  LOVy'ER   EXTREMITY 

Gait. — ^The  gait  of  the  patient  with  well-marked  genu  valgum  is 
peculiarly  awkward  and  shambling.  The  knees  "interfere"  and 
must  be  assisted,  as  it  were,  in  the  effort  to  pass  one  another  in 
walking.  In  the  slighter  cases  the  thigh  is  abducted  and  rotated 
■  outward  at  the  moment  of  passing  its  fellow,  the  movement  being 
then  reversed  as  it,  in  its  tm-n,  supports  the  weight;  but  in  the  more 
severe  t^-pe  this  voluntary  effort  of  the  muscles  of  the  leg  is  not 
sufficient,  and,  in  addition,  the  body  is  swayed  from  side  to  side 
and  the  legs  are  alternately  swung  outward  and  lifted  around  one 
another. 


Fig.  456. — Skiagram  of  Fig.  452,  showing  the  deformity  to  be  due  to  distortions  of 
the  diaphyses  of  the  bones,  while  the  epiphyses  are  practically  normal. 


The  deformity  and  the  effects  of  the  deformity  on  the  gait  and 
attitude  are  the  most  important  symptoms,  as  of  other  distortions 
of  similar  origin.  The  patient  is,  as  a  rule,  easily  fatigued,  and  pain 
during  the  progressive  stage,  referred  to  the  inner  side  of  the  knee, 
where  the  ligaments  are  subjected  to  continuous  strain,  is  a  common 
symptom,  particularly  in  the  adolescent  type  of  genu  valgum. 

Unilateral  Knock-knee. — This  description  refers  particularly  to  the 
cases  in  which  the  deformity  is  bilateral.     Not  infrequently  it  is 


GENU   VALGUM 


593 


unilateral,  the  limb  being  so  shortened  by  the  distortion  that  a  well- 
marked  limp  replaces  the  swaying  gait.  The  pelvis  is  tilted  toward 
the  short  limb,  while  the  body  is  inclined  in  the  opposite  direction, 
thus  in  cases  of  long  standing  a  permanent  curvature  of  the  lumbar 
spine  may  be  present. 

Knock-knee  Combined  with  Bow-leg   and  with  General  Rhachitic 
Distortions. — Occasionally  the  unilateral  knock-knee  may  be  accom- 
panied by  an  outward  bowing  of  its  fellow;  and  in  the  marked  dis- 
tortions of  the  lower  extremity, 
induced  Ijy  rhachitis,  the  bones 
may  be    twisted   and  bent  in 
various  directions,  although  the 
outward   expression  of  the  de- 
formity may  be   genu  valgum. 
For  example,  the  femora  may 
be  bent  forward  and  outward 
above    and   inward   and  back- 
ward   below,    while    the    tibiae 
may  be  bent  inward  above  and 
outward  and  forward  below. 

In  other  instances,  especially 
in  the  slighter  rhachitic  de- 
formities, an  outward  bowing 
of  the  leg  may  accompany  a 
slight  degree  of  knock-knee,  so 
that  it  may  be  difficult  to 
classify  the  deformity. 

In  the  more  extreme  deform- 
ities of  the  rhachitic  type  the 
shape  as  well  as  the  contour  of 
the  bones  is  markedly  modified, 
for  example,  the  internal  border 
of  the  tibia  may  become  very 
prominent  at  its  upper  extrem- 
ity, and  may  project  beneath 
the  skin  like  an  exostosis  (Fig. 
458).  A  change  in  the  contour 
of  the  fibula  accompanies  and 
corresponds  to  that  of  the  tibia, 
although  it  is,  as  a  rule,  much  less  pronounced.  As  has  been  stated, 
the  internal  structure  or  architecture  of  the  affected  bones  is 
changed  to  accommodate  the  new  static  conditions,  and  according 
to  Wolff  the  internal  change  precedes  the  external  deformity. 

Measurements. — ^There   are   various  methods   of  measuring    the 

deformity.     One  of  the  simplest  and  most  practical  is  to  trace  the 

outlines  on  paper,  while  the  child  is  seated  with  the  limbs  fully 

extended,  the  knees  being  sufficiently  separated  to  allow  the  pencil 

38 


Fig.  457. — Deformity  of  the  femur  in 
genu  valgum.     (Mikulicz.) 


594       DEFORMITIES  OF  BOXES  OF  LOWER  EXTREMITY 

to  pass  between  them.  The  mcrease  of  the  deformity,  dependmg 
upon  the  laxity  of  the  Hgaments  and  upon  the  outward  rotation  of 
the  tibiae,  may  be  estimated  by  measuring  the  distance  between  the 
two  mternal  malleoh  when  the  patient  stands,  the  knees  being 
sKghtly  separated  as  before,  and  comparmg  this  measurement  with 
that  between  the  similar  points  in  the  tracing. 


Fig.  458. — Knock-knee  and  bow-leg. 

Pathology. — In  knock-knee  due  directly  to  rhachitis  the  changes 
in  the  bones  and  in  the  epiphyseal  cartilages  are  characteristic  of 
that  affection,  but  m  the  milder  grades  of  deformity,  aside  from  the 
change  in  the  contour  of  the  bones,  the  transformation  of  the  inter- 
nal structure,  and  in  some  instances  slight  thickening  or  irregularity 
of  the  epiphyseal  cartilages,  there  is  little  noteworthy  change  from 
the  normal  (Fig.  457).  The  tissues  on  the  internal  aspect  of  the 
joint  are  relaxed;  those  on  the  outer  side,  the  lateral  ligaments,  the 


GENU   VALGUM 


595 


capsule,  and  the  biceps  muscle,  are  contracted  and  resist  the  reduc- 
tion of  the  deformity.  In  the  interior  of  the  joint  slight  changes  in 
the  articulating  surfaces  of  the  bones  and  evidences  of  chronic  irri- 
tation to  the  synovial  membrane  have  been  described. 

In  the  early  stage  of  progressive  knock-knee,  particularly  in  the 
type  not  caused  directly  by  rhachitis,  laxity  of  ligaments  and  the 
habitual  assumption  of  the  attitude  of  rest  will  account  for  the 
deformity,  which  the  patient  may  be  able  to  overcome,  in  great 
degree  at  least,  by  voluntary  effort.  This  voluntary  control  of  the 
deformity  is  very  suggestive,  as  indicating  certain  factors  in  its 
etiology,  and  the  principles  that  should  be  followed  in  its  treatment. 

Treatment. — The  treatment  of  the  deformity  under  considera- 
tion may  be  classified  as  expectant,  mechanical,  and  operative. 


Fig.  459. 


-Adolescent  knock-knee,  showing  the  disappearance  of  the  deformity  when 
legs  are  flexed.      (See  Fig.  455.) 


Expectant  Treatment. — This  should  not  be  expectant  in  the  sense 
that  nothing  is  done  to  correct  the  deformity,  but  expectant  in  that 
more  positive  treatment  by  braces  or  by  operation  is  delayed  or 
avoided  if  it  proves  to  be  unnecessary. 

During  this  period  the  predisposing  cause  of  the  deformity,  if  it  is 
constitutional,  should  receive  proper  dietetic  or  medicinal  treatment, 
as  already  described  in  the  chapter  on  Rhachitis.  And,  if  possible, 
the  direct  exciting  causes  of  the  deformity  must  be  removed — that 
is  to  say,  the  improper  attitudes,  or,  in  the  adolescent,  the  predis- 
posing occupations  should  be  discontinued.  General  massage  of  the 
limbs  may  be  employed  with  advantage;  in  older  children  special 
exercises  may  be  practised,  and  in  all  cases,  whether  braces  are  used 


596       DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 

or  not,  direct  manipulation  of  the  distorted  limbs  is  of  the  first 
importance. 

Manipulation. — The  limbs  should  be  vigorously  massaged  at  morn- 
ing and  night,  and  forcibly  straightened.  The  latter  procedure  is 
conducted  as  follows:  The  patient  is  seated  in  a  chair,  the  limb 
being  fully  extended  so  that  the  deformity  is  made  as  extreme  as 
possible.  One  hand  then  clasps  the  knee,  the  palm  lying  against 
its  inner  aspect;  with  the  other  the  calf  is  grasped  firmly  and  the 
leg  is  then  gently  straightened  over  the  fulcrum  formed  by  the  palm 
of  the  hand,  and  is  held  in  the  corrected  position  for  a  moment. 
This  manipulation  should  be  continued  with  gradually  increasing 
force,  although  not  to  the  extent  of  causing  actual  pain,  for  ten 
minutes  at  least  twice  in  the  day  and  oftener  if  possible. 

Posture  and  Exercise. — It  has  been  stated  that  genu  valgum  is 
often  accompanied,  especially  in  the  rhachitic  cases,  by  flat-foot, 
while  in  another  t\'pe  the  inversion  of  the  feet,  or  in  the  more  severe 
the  actual  fixed  attitude  of  varus,  indicates  the  effort  of  nature  to 
withstand  and  to  compensate  for  the  deformity  at  the  knee.  This 
serves  as  an  indication  to  thicken  the  soles  of  the  shoes  on  the  inner 
border  or  to  apply  direct  support  as  in  the  treatment  of  flat-foot,  in 
order  to  throw  the  strain  upon  the  outer  border  of  the  foot.  The 
patient  should  be  instructed  to  walk  with  the  feet  parallel  with  one 
another,  and  for  older  children  the  tip-toe  exercises,  in  which  the 
body  is  raised  upon  the  toes  as  many  times  as  the  strength  permits, 
or  games  or  exercises  in  which  the  legs  are  extended  should  be 
encouraged.  Such  exercises  are  often  efficacious  in  the  early  stage 
of  adolescent  knock-knee,  for,  as  has  been  mentioned,  genu  valgum 
is  an  exaggeration  of  the  attitude  of  rest;  therefore  its  progress 
should  be  checked  by  the  assumption  of  the  attitudes  proper  to 
activity.  Bicycle  riding,  and  particularly  horseback  riding  may  be 
recommended  also  in  this  class  of  cases.  A  record  of  the  deformity 
should  be  kept  during  this  tentative  treatment,  and  if  it  improves 
somewhat  one  is  justified  in  delaying  the  more  radical  measures. 
This  question  may  be  decided,  as  a  rule,  in  three  months  if  instruc- 
tions are  faithfully  followed. 

Treatment  by  Braces. — ^The  most  efficient  brace  for  the  treatment 
of  genu  valgum  is  the  simple  straight  steel  bar  or  splint  extending 
from  the  trochanter  to  the  heel  of  the  shoe,  without  joint  at  the 
knee.  The  greater  efficacy  of  the  rigid  bar  as  compared  with  the 
jointed  brace  is  explained  by  the  fact  that  the  rectifying  force  acts 
constantly  when  the  joint  is  fixed,  and  because,  in  many  instances, 
the  patient  habitually  flexes  the  knees  so  that  direct  pressure  can- 
not be  made  upon  the  deformity  by  a  brace  that  permits  this 
attitude. 

The  Thomas  Bkace. — ^The  simplest  and  cheapest  brace  is  that  of 
Thomas,  which  consists  of  a  light  steel  bar  provided  with  a  pad  at 
its  upper  end  for  pressure  against  the  trochanter,  while  the  lower. 


GENU   VALGUM 


597 


rounded  extremity  is  turned  inward  at  a  right  angle,  to  pass  through 
the  heel  of  the  shoe.  The  knee  is  fixed  by  a  posterior  bar  attached 
to  a  thigh  and  calf  band,  as  illustrated  in  the  figure.  When  the  brace 
is  applied  the  knee  is  drawn  backward  and  outward  and  is  attached 
firmly  to  the  brace  by  a  roller  bandage  (Fig.  460) . 


Fig.  460.— The  Thomas  knock- 
knee  brace. 


Fig.  461. — Thomas  knock-knee  brace  with 
pelvic  band.  The  pelvic  band  may  be  divided 
also,  the  two  parts  being  joined  by  straps  (Fig. 
462.) 


In  the  more  extreme  cases  in  which  the  knees  and  thighs  are 
habitually  flexed,  the  addition  of  a  pelvic  band  attached  to  the 
uprights  by  a  free  joint  at  the  hips  adds  to  the  comfort  and  efficiency 
of  the  apparatus,  as  the  attitude  of  outward  or  inward  rotation  can 
be  regulated  by  twisting  the  uprights  slightly.  Or  preferably  the 
the  pelvic  band  may  be  divided  and  attached  by  means  of  straps  on 
the  front  and  back.  The  uprights  may  be  bent  somewhat  inward 
at  first,  and  as  the  legs  become  straighter  they  are  straightened  and 


598       DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 

finally  bent  slightly  outward  to  allow  for  the  overcorrection  of  the 
deformity  (Fig.  462).  Twice  a  day  the  braces  should  be  removed 
for  massage,  manipulation,  and  for  voluntary  exercises  of  the  limbs. 
In  most  cases  the  braces  are  not  employed  at  night,  although  the 
rectification  of  the  deformit}^  may  be  hastened  by  their  constant  use. 
If  the  deformity  is  unilateral  so  that  a  brace  is  required  for  one 
limb  only,  the  other  shoe  should  be  raised  by  a  cork  sole  about 
three-quarters  of  an  inch  in  thickness,  to  make  walking  easier. 


Fig.  462. — Modified  Thomas  kiiock-kiiee  braces  applied. 


Children  soon  become  accustomed  to  the  braces  and  walk  easily 
in  spite  of  the  absence  of  joints  at  the  knees. 

x\nother  simple  and  efficient  brace  is  that  used  at  the  Children's 
Hospital  at  Boston  (Fig.  463).  The  upper  part  of  the  brace  is 
turned  backward  and  upward  to  lie  against  the  buttock,  and  the 
feet  may  be  rotated  in  or  out  by  lengthening  or  shortening  straps 
passing  before  and  behind  the  body.     Braces  jointed  at  the  knee 


GENU   VALGUM 


599 


are  sometimes  employed,  but  they  are,  as  a  rule,  ineffective,  except 
in  the  slighter  cases  in  which  the  deformity  depends  upon  laxity  of 
ligaments  rather  than  distortion  of  bone. 

Duration  of  Treatment  by  Braces. — ^The  duration  of  the  brace 
treatment  depends,  of  course,  upon  the  degree  of  deformity,  the 
age  of  the  child,  and  upon  the  efficiency  of  the  apparatus.  From 
six  months  to  one  year  of  treatment  by  this  means  is  usually  required. 
The  cure  is  assured  by  the  gradual  adaptation  of  the  parts  to  the 
new  static  conditions.  The  contracted  tissues  of  the  outer  aspect  of 
the  joint  become  lengthened;  the  lax  ligaments  on  the  inner  side 
contract;  the  internal  structure  of 
the  condyles  and  of  the  adjoining 
diaphysis  is  gradually  transformed 
and  at  the  external  contour  of 
the  bone  becomes  correspondingly 
straighter.  When  the  braces  are 
discarded  attention  should  be  paid 
to  the  attitudes,  and  the  exercises 
that  have  been  mentioned  should 
be  continued  in  order  that  relapse 
may  be  prevented. 

The  Plaster  Bandage. — When 
the  bones  are  yielding,  as  in  young 
children,  the  deformity  may  be 
corrected  by  the  repeated  appli- 
cations of  plaster  bandages,  the 
limbs  being  straightened  as  far  as 
possible  without  causing  discomfort 
at  each  sitting,  or  it  may  be  cor- 
rected at  once  by  manual  force 
under  anesthesia,  which  is  the 
better  method. 

Operative  Treatment.  —  Imme- 
diate correction  of  the  deformity, 
when  it  is  at  all  marked,  is,  as  a 
rule,  indicated  after  the  age  of  four 
or  five  years,  and  is  a  satisfactory 

treatment  at  any  age  except  during  the  period  of  active  rhachitis. 
It  is  perhaps  needless  to  remark  that  the  necessity  for  operation 
implies  neglect  of  proper  preventive  treatment  or  the  failure  of 
the  manipulative  and  mechanical  methods,  because  of  their  improper 
application.  While  it  is  possible  to  correct  deformity  of  the  bones 
by  mechanical  treatment  in  cases  far  beyond  this  limit  of  age,  the 
time  required  and  the  discomforts  of  the  treatment  exclude  it  in  all 
but  very  exceptional  cases. 

Osteotomy. — In  1915,  97  cases  of  knock-knee  were  operated  on 
at  the  Hospital  for  Ruptured  and  Crippled;  43  per  cent,  of  the  new 


Fig.  463. — -Long  braces  for  genu  val- 
gum.    (Bradford  and  Lovett.) 


600      DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 

cases  of  knock-knee  recorded  in  the  out-patient  department.  The 
routine  operation  was  osteotomy  (95  cases)  by  means  of  the  small 
Vance  osteotome,  the  so-called  "subcutaneous  osteotomy."  In  a 
certain  proportion  of  the  cases  the  bones  of  the  thigh  and  leg  are 
equally  involved  in  the  deformity.  In  others  the  tibia  is  the  more 
distorted,  but  in  most  instances  the  correction  of  the  deformity  of 
the  femur  will  practically  restore  the  normal  contour  (Fig.  457) . 

The  limb  having  been  prepared  in  the  usual  manner  is  semi- 
flexed, and  the  inner  surface  of  the  knee  is  placed  on  a  firm  sand- 
bag. With  the  fingers  the  femur  is  firmly  grasped  just  above  the 
condyles,  so  that  its  size  and  position  may  be  accurately  determined, 
and  the  sharp  osteotome  about  the  size  of  a  lead-pencil  is  forced 
with  its  cutting  edge  parallel  to  the  axis  of  the  thigh  down  to  the 
bone,  at  a  point  about  one  inch  above  the  external  tuberosity. 
While  it  is  held  firmly  in  position  against  the  bone  it  is  turned  in  the 
transverse  direction  and  is  then  driven  through  the  cortex.  When 
it  enters  the  medullary  canal,  as  is  made  evident  by  the  lessened 
resistance,  it  is  partly  withdrawn  and  moved  slightly  to  one  side  and 
the  other,  and  driven  through  the  cortical  substance  until  by  gentle 
force  the  bone  may  be  fractured.  The  osteotome  is  then  with- 
drawn; the  minute  wound  is  covered  with  a  pad  of  dry  gauze,  or, 
if  the  oozing  is  profuse,  it  may  be  closed  with  a  catgut  suture.  The 
deformity  is  then  overcorrected  sufiiciently  to  simulate  well-marked 
genu  varum,  and  a  plaster  spica  bandage  is  applied.  If  the  deform- 
ity is  bilateral  both  limbs  are  operated  upon  at  the  same  sitting. 

The  plaster  bandage  is  continued  for  from  four  to  six  weeks,  and 
it  is  then  usually  supplemented  by  a  brace,  which  may  be  worn  with 
advantage  for  several  months,  because  of  the  laxity  of  the  ligaments 
of  the  knee-joint,  which  usually  accompanies  extreme  deformity  of 
rhachitic  origin.  In  less  marked  cases  and  in  older  subjects  the 
support  is  unnecessary.  jMassage  and  exercises  during  the  stage  of 
recovery  should  be  employed  if  possible. 

Incomplete  osteotomy  and  fracture  in  the  manner  described  have 
been  employed  at  the  Hospital  for  Ruptured  and  Crippled  in  a  very 
large  nmnber  of  cases  without  an  unfavorable  result.  The  discom- 
fort is  insignificant,  and  confinement  to  bed  after  the  third  day 
is  unnecessary. 

Cuneiform  Osteotomy. — ^In  the  more  extreme  cases  of  general 
rhachitic  deformity  of  the  lower  extremity  in  which  the  tibia  is 
implicated,  it  is  sometimes  necessary,  m  addition  to  the  osteotomy 
of  the  femur,  to  fracture  the  tibia  also  in  order  to  distribute,  as  it 
were,  the  correction.  In  such  cases  it  may  be  advisable  to  remove  a 
cuneiform  section  of  bone  from  the  inner  side  of  the  tibia  just  below 
the  epiphysis  for  more  symmetrical  adjustment  of  the  fracture. 
In  such  cases  it  is  better  to  perform  the  second  operation  at  a  later 
time  in  order  that  the  effect  of  the  femoral  osteotomy  may  be 
observed.     In  exceptional  cases  the  deformity  may  be  practically 


GENU   VALGUM 


601 


confined  to  the  tibia;  in  such  instances  it  should  be  corrected  by  a 
primary  cuneiform  or  linear  osteotomy. 

Osteoclasis. — Osteoclasis,  by  means  of  the  Grattan  osteoclast, 
is  an  effective  operation.  With  this  instrument  the  bone  may  be 
broken  above  the  condyles  at  the  desired  point.  The  lower  resistant 
bar  is  applied  over  the  external  condyle,  the  upper  about  four 
inches  higher.  The  limb  is  then  firmly  fixed  by  the  hands  of  an 
assistant,  and  the  breaking  bar  is  screwed  rapidly  home,  breaking 
or  bending  the  bone  at  the  point  of  election.  The  deformity  is  then 
overcorrected  in  the  manner  described.  Not  infrequently  in  rha- 
chitic  cases  the  principal  or  primary  distortion  is  of  the  tibia.  In 
such  cases  the  correction  is  made  at  this  point.  If  it  is  necessary 
to  operate  upon  both  the  femur  and  the  tibia  the  osteoclast,  which 
bends  and  breaks,  is  to  be  preferred  to  osteotomy. 


Fig.  464. — The  Grattan  osteoclast. 

The  adolescent  type  of  genu  valgum  is  not  often  extreme.  As  a 
rule  the  deformity  of  the  bone  is  of  comparatively  short  duration, 
and  it  is  accompanied  by  considerable  laxity  of  ligaments.  In  the 
well-marked  cases  osteotomy  above  the  condyles  may  be  per- 
formed in  the  manner  described. 

Wolff's  treatment  of  gradual  correction  by  plaster-of-Paris  ban- 
dages ("Etappen  Verband")  and  Lorenz's  method  of  epiphyseal 
separation  described  in  former  editions  have  been  omitted  as  offering 
no  advantage  over  osteotomy  or  osteoclasis. 

It  may  be  noted  that  paralysis  due  to  injury  of  the  peroneal  nerve 
may  follow  the  correction  of  knock-knee.  In  a  total  of  1863  opera- 
tions by  osteoclasis  reported  by  Codivilla^  there  were  34  instances 
of  the  paralysis,  2  of  which  were  permanent. 


1  Ztschr.  f.  ortliop.  Chir. 


602       DEFORMITIES  OF  BOXES  OF  LOWER  EXTREMITY 

GENU  VARUM. 

Sjmonym. — Bow-leg. 

The  term  boyv-leg  includes,  in  its  popular  sense,  all  the  distortions 
that  cause  a  separation  of  the  knees  when  the  ankles  are  in  contact 
with  one  another.     But.  strictly  speaking,  genu  varum  is  the  reverse 


Fig.  465. — The  genu  varum  type  of 
bow-leg,  showing  the  outward  rota- 
tion of  the  femora. 


Fig.  466. — The  same  patient,  showing 
the  separation  of  the  malleoli  when  the 
knees  are  in  contact. 


of  genu  valgum — that  is,  the  principal  distortion  is  at  or  near  the 
knee-joint — while  bow-leg,  as  the  name  implies,  is  a  simple  bowing 
of  the  tibia  and  fibula,  as  a  rule,  near  the  ankle-jomt  (Fig.  -i72).  In 
true  genu  varum  a  line  dropped  from  the  head  of  the  femur  falls 
inside  the  knee  (Fig.  451) ;  the  inner  condyle  of  the  femur  and  the 
imier  tuberosity  of  the  tibia  bear  the  greater  part  of  the  weight;  the 


GENU   VARUM 


603 


outer  condyle  is  on  the  same  level  or  somewhat  lower  than  the  inter- 
nal, and  the  outer  tuberosity  of  the  tibia  may  be  somewhat  higher 
than  the  internal.  The  femur  is  abducted  and  rotated  outward; 
the  tibia  is  rotated  inward.  These  changes,  it  will  be  noted,  are 
the  reverse  of  those  found  in  genu  valgum.  As  has  been  stated,  the 
deformity  of  genu  valgum  disappears  on  flexion,  and  in  genu  varum, 
if  the  limbs  are  flexed  and  the  knees  are  placed  in  contact  with  one 
another,  the  malleoli  may  be  actually  separated,  simulating  the 
deformity  of  knock-knee  (Fig.  466) .  This  is  explained  by  the  inward 
rotatiomof  the  femora,  necessitated  by  placing  the  knees  in  contact 
with  one  another. 


Fig.  467. — Genu  varum  of  rhachitic  origin  in  an  adult. 


In  genu  varum  the  distortion  of  the  bones  is  not  as  strictly][con- 
fined  to  the  neighborhood  of  the  knee-joint  as  in  genu  valgum,  and 
in  simple  bow-leg  there  is  almost  always  a  certain  degree  of  d'stor- 
tion  at  the  knee,  dependent,  in  part,  upon  laxity  of  the  ligaments. 
It  is  proper,  therefore,  to  use  the  two  terms  synonymously,  although 
one  must  recognize  a  decided  difference  between  the  genu  varum 
type,  in  which  the  deformity  is  greatest  at  the  knee,  and  which  is 
accompanied,  as  a  rule,  by  marked  laxity  of  the  ligaments  (Fig.  467) 
and  the  bow-leg  type,  in  which  the  deformity  may  be  limited  to  the 
lower  third  of  the  leg  (Fig.  472). 


604      DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 


Symptoms. — As  was  said  of  genu  valgum,  the  deformity  is  the 
principal  s^^Ilptom.  The  gait  is  somewhat  rolling,  because  each 
foot  must  describe  a  part  of  the  arc  of  a  circle  before  reaching  the 
ground;  and  because  of  the  inward  rotation  of  the  tibiae,  or  because 
of  the  inward  spiral  twist  of  the  bone  that  is  sometimes  present, 
patients  often  toe-in  in  walking. 

Except  in  extreme  cases  the  weakness  and  awkwardness  char- 
acteristic of  genu  valgum  are  absent.  This  may  be  explained  by 
the  fact  that  the  relation  of  the  bones  is  such  that  the  general  atti- 
tude is  one  of  activity,  the  weight  falling  on  the  outer  side  of  the 

feet;  thus  the  weak  foot  is  uncommon 
as  an  accompaniment  of  bow-leg,  ex- 
cept in  the  early  or  rhachitic  t^^)e  or 
as  a  compensatory  deformity  in  older 
subjects. 

Measurements.  —  The  full  effect  of 
the  deformity  appears  only  when  the 
weight  of  the  body  is  borne,  but  for 
practical  purposes  the  tracmg  of  the 
extended  legs  is  the  best  method  of 
recordmg  the  fixed  deformity.  In  true 
genu  varum  the  deformity  is  greatest 
at  the  knee,  and  in  the  distortion  the 
apposed  surfaces  of  the  femur  and  of 
the  tibia  participate. 

In  simple  bow-leg  the  deformity 
may  be  confined  to  the  tibia,  which 
in  addition  to  the  outward  bowing, 
may  be  twisted  inward  somewhat  upon 
its  long  axis. 

Genu  varum  may  be  unilateral  or  it 
may  be  combined  with  genu  valgum 
of  its  fellow  (Fig.  458),  and  occasion- 
ally slight  knock-knee  and  slight  bow- 
leg may  be  present  in  the  same  limb. 
Treatment. — Expectant  Treatment. — ^The  slighter  cases  of  bow-leg 
m  early  childhood  may  be  treated  by  manipulation.  The  leg, 
grasped  firmly  at  the  ankle  and  at  the  knee,  is  straightened  with  a 
certain  amount  of  force  over  and  over  again.  Gradual  correction 
by  this  means  may  be  hastened  by  making  the  sole  of  the  shoe 
slightly  thicker  on  the  outer  border.  This  aids  also  in  correcting 
the  secondary  pigeon-toe,  but  if  the  foot  is  weak,  as  it  usually  is  in 
rhachitic  cases,  this  method  should  not  be  employed,  as  it  might 
induce  flat-foot. 

Treatment  by  Braces. — If  the  deformity  is  more  extreme,  or  if 
improvement    does    not    follow    expectant    treatment,    apparatus 


Fig.  468.- 
genu  varum 
Lovett.) 


-Long    braces     for 
(Bradford     and 


GENU   VARUM 


605 


should  be  employed.  If  the  distortion  is  confined  to  the  lower 
third  of  the  tibia  a  Knight  brace  may  be  used.  It  consists  of  two 
uprights  attached  to  a  foot  plate;  the  inner  bar  is  provided  with  a 
pad  at  its  upper  end  for  pressure  on  the  internal  condyle  of  the  femur. 
The  outer  bar  reaches  to  the  head  of  the  fibula,  and  the  two  are 
joined  by  a  calf  band  (Fig.  469).  When  applied  the  leg  is  drawn 
toward  the  inner  upright  by  means  of  a  lacing,  which  passes  about 
it  within  the  outer  bar.  When  the  lacing  is  made  fast,  the  outer 
bar  is  adjusted  to  the  contour  of  the  leg,  and  thus  it  aids  somewhat 
in  supporting  it  in  an  improved  position.  The  foot  plate  may  be 
dispensed  with,  and  the  brace  may  be  attached  to  the  shoe,  and  even 


Fig.  469. — The  long  (Napier)  and  short  (Knight)  bow-leg  brace. 


the  outer  bar  may  be  removed,  leaving  only  the  upright,  which  is 
held  in  position  by  the  lacing.  The  apparatus,  then,  has  the 
appearance  of  a  gaiter,  and  has  the  advantage  of  being  inconspicu- 
ous, although  somewhat  less  effective  than  the  Knight  brace.  If 
the  support  is  supplemented  by  vigorous  manipulation  the  deformity 
may  be  corrected,  in  young  children,  in  about  six  months. 

If  the  outward  bowing  of  the  knee  is  marked  another  form  of 
apparatus  will  be  necessary,  and  its  effectiveness  will  be  much 
increased  if  there  is  no  joint  at  the  knee.  The  inner  bar  reaches 
to  the  upper  third  of  the  thigh.  An  inner  straight  bar  extends  to 
the  upper  third  of  the  thigh,  and  is  attached  to  the  outer  bar  by  a 


606       DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY 

thigh  band.  This  inner  upright  is  provided  with  a  lacing  of  leather 
or  canvas,  similar  to  that  of  the  short  brace,  which  surrounds  the 
knee  and  upper  part  of  the  leg,  and  thus  draws  it  toward  an  improved 
position  (Fig.  469). 

Another  form  of  brace  is  used  at  the  Boston  Children's  Hospital, 
m  which  the  upper  part  of  the  upright  is  curved  upward  and  out- 
ward just  below  the  groin,  to  a  point  on  a  level  with  and  behind 
the  trochanter,  and  is  attached  to  its  fellow  by  means  of  a  strap 
passing  across  the  buttocks  so  that  the  feet  may  be  somewhat 
rotated  outward  if  necessary  (Fig.  468). 

Operative  Treatment. — In  children  over  four  years  of  age,  and  in 
cases  of  the  more  extreme  type  at  an  earlier  age,  or  when  the  oppor- 
tunity for  mechanical  treatment  is  lacking,  or  if  rapid  cure  is  desired, 
operative  correction  of  the  deformity  is  indicated.  Either  osteo- 
clasis or  osteotomy  may  be  employed,  and  in  some  instances  manual 
force  is  sufficient  for  the  correction  of  the  deformity.  There  is  but. 
little  choice  between  the  methods.  Osteoclasis  is  somewhat  safer 
possibly,  and  is  to  be  preferred  for  the  younger  patients. 

At  the  Hospital  for  Ruptured  and  Crippled  in  1915,  89  patients, 
or  about  20  per  cent,  of  the  new  cases  of  bow-leg  recorded  in  the 
outdoor  department  (444)  were  admitted  for  operation.  Oste- 
otomy is  usually  performed.  The  small  osteotome  is  inserted  on 
the  inner  aspect  of  the  tibia  at  the  point  of  greatest  deformity, 
and  when  the  bone  has  been  sufficiently  weakened  the  fracture  is 
completed  by  manual  force.  The  fibula  may  be  broken  at  the  same 
time,  or,  as  is  usually  the  case,  it  may  be  simply  bent  outward.  The 
deformity  is  overcorrected,  and  a  well-fitting  plaster  bandage,  includ- 
ing the  foot  and  extending  to  the  trochanter,  is  applied. 

The  patient  usually  remains  in  bed  for  a  few  days;  he  is  then 
dressed,  and  if  he  so  desires  is  allowed  to  stand.  Almost  no  pain  or 
discomfort  follows  the  operation,  and  in  fact,  in  properly  selected 
cases,  it  is  not  only  free  from  danger,  but  it  has  a  very  decided  advan- 
tage over  the  ordinary  mechanical  treatment.  If  the  child  is  in 
good  condition,  and  if  the  deformity  is  overcorrected  at  the  time  of 
operation,  apparatus  will  not  be  required  in  the  after-treatment; 
but  in  many  instances  some  form  of  support  is  indicated,  usually 
because  slight  deformity,  due  to  laxity  of  ligaments  or  to  deformity 
of  the  femur,  appears  when  the  weight  of  the  body  falls  upon  the 
legs. 

It  has  been  stated  that  the  deformity  of  bow-leg  depends  in  part 
upon  a  distortion  of  the  femur  as  well  as  of  the  tibia.  As  a  rule  the 
correction  of  the  greater  deformity  of  the  tibia  will  be  sufficient,  but 
in  more  extreme  cases  a  secondary  osteotomy  above  the  condyles 
will  be  necessary.  This  may  be  performed  simultaneoush'  with  that 
on  the  tibia,  but  it  is  better  to  defer  it  until  the  eft'ect  of  the  primary 
operation  has  been  observed. 


ANTERIOR  BOW-LEG  607 


ANTERIOR  BOW-LEG. 

Synonym. — Anterior  curvature  of  the  tibia. 

Both  bow-leg  and  knock-knee  are  often  seen  in  children  who 
present  no  signs  of  general  rhachitis,  but  anterior  bowing  of  the 
legs  is  almost  always  combined  with  general  rhachitic  distortions 
of  the  lower  extremity,  most  often  with  knock-knees.  These  in 
turn  are  caused  by  marked  distortion  of  the  femora,  which  may  be 
bent  forward  and  outward  above,  and  inward  at  their  lower  extremi- 
ties, "corkscrew  deformity."  In  anterior  bow-leg  the  tibiae  are 
usually  flattened  from  side  to  side,  curved  inward  or  outward  and 
bent  forward,  the  projecting  crests  presenting  sharply  beneath  the 
skin. 


Fig.  470. — Anterior  bow-leg. 

Symptoms. — The  effect  of  the  anterior  bowing  is  to  throw  the 
weight  forward  upon  the  foot;  thus  the  heels  appear  abnormally 
long  and  prominent,  and  the  patient  seems  to  sink  forward  at  each 
step  (Fig.  470).  The  knees  are  usually  somewhat  flexed,  partly  as 
the  eft'ect  of  knock-knee,  with  which  the  deformity  is  usually  com- 
bined, and  the  feet  are,  as  a  rule,  flat.  As  has  been  stated,  anterior 
bowing  is  almost  never  seen  as  an  independent  deformity  unless  it 
is  a  relic  of  the  more  general  distortion  which  has  been  "outgrown." 

Treatment. — Anterior  curvature  of  the  tibia  must,  as  a  rule,  be 
treated  by  operation,  preferably  osteotomy.  After  complete  frac- 
ture of  the  tibia  and  fibula  the  deformity  may  be  overcome  by  forc- 
ing the  bones  directly  backward.  In  many  instances  tenotomy  of 
the  tendo-Achillis  may  be  required.  Cuneiform  osteotomy  of  the 
tibia  permits  more  perfect  correction,  but  the  final  result  is  equally 
good  after  simple  osteotomy  or  osteoclasis,  and  if  one  succeeds  in 


608       DEFORMITIES  OF  BOXES  OF  LOWER  EXTREMITY 


Fig.  471. — Long  anterior  cui'vature  of  the  tibia  and  flat-foot. 


Fig.  472. — Rhachitic  anterior  bow-leg. 


GENERAL  RHACHITIC  DISTORTIONS  609 

separating  the  posterior  part  of  the  tibia  so  that  it  may  conform  to 
the  straightened  anterior  border  an  actual  elongation  may  be 
obtained. 

GENERAL  RHACHITIC  DISTORTIONS. 

General  rhachitic  distortions  of  the  lower  limbs  have  been  men- 
tioned in  connection  with  knock-knee  and  with  anterior  bow-leg. 
A  more  extended  description  is  hardly  necessary.  The  deformities 
are  usually  of  the  knock-knee  type,  and  they  may  be  treated  on  the 
same  general  plan  that  has  been  outlined  in  the  description  of  the 
less  extreme  distortions. 


39 


CHAPTER  XVII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 

From  the  orthopedic  stand-point  only  those  diseases  that  directly 
interfere  with  the  function  of  locomotion  or  that  cause  deformity 
for  which  local  treatment  is  of  benefit  are  of  special  interest.  Even 
this  limited  class  is  not  often  seen  in  the  early  or  progressive  stage, 
and  it  is  rather  with  the  effects  of  a  disease  that  is  no  longer  present 
than  with  the  disease  itself  that  the  orthopedic  surgeon  is  especially 
concerned. 

The  relative  importance  of  this  branch  of  orthopedic  work  under 
normal  conditions  may  be  illustrated  by  the  statistics  of  the  Hos- 
pital for  Ruptured  and  Crippled.  In  the  year  1909,  7296  new 
patients  were  examined  in  the  out-patient  department.  In  1114  of 
these  the  nervous  system  was  involved. 

Anterior  poliomyelitis  furnished  507,  about  46  per  cent,  of  the 
total  number.     In  293,  or  22  per  cent.,  the  cerebriun  was  involved. 

ACUTE  ANTERIOR  POUOMYEUTIS. 

Anterior  poliomyelitis  is  an  acute  infectious  disease  that  involves 
the  spinal  cord.  It  is  caused  by  a  minute  filtrable  germ  or  virus, 
apparently  introduced  at  the  upper  respiratory  passages. 

The  infection  reaches  the  spinal  cord  through  the  bloodvessels, 
and  possibly  by  the  IjTnph  channels.  Primarily,  it  is  an  interstitial 
meningitis  accompanied  by  an  increase  of  the  spinal  fluid. 

The  changes  in  the  cord  are  most  marked  at  its  anterior  portion, 
at  the  lumbar  and  cervical  enlargements,  although  the  medulla, 
pons  and  other  parts  of  the  brain  are  frequently  involved  and  also 
the  posterior  root  ganglia.  There  is  an  initial  hyperemia,  an  accu- 
mulation of  small  round  cells  in  the  lymph  spaces,  minute  hemor- 
rhages and  edema.  These  changes  are  most  marked  in  the  anterior 
horns  of  gray  matter,  but  are  not  confined  to  it. 

The  nerve  cells  are  injured  or  destroyed  in  part  by  the  mechanical 
effect  of  the  disease  and  in  part  by  the  toxic  action  of  the  vu'us,  and 
are  replaced  by  scar  tissue. 

Primarily,  the  paralysis  is  widespread  because  of  interference 
with  function  caused  by  congestion  and  edema.  Eventually,  the 
area  is  determined  by  the  actual  damage  to  the  nerve  cells  and  con- 
ducting tracts. 

The  disease  is  somewhat  more  common  among  males  than 
females  and  those  in  perfect  health  are  as  susceptible  as  those  whose 
resistance  is  enfeebled.  It  is  endemic  and  at  intervals  becomes 
epidemic,  as  in  New  York  in  1907  and  1916. 


ACUTE  ANTERIOR  POLIOMYELITIS 


611 


Age. — Acute  anterior  poliomyelitis  is  essentially  a  disease  of  early 
childhood,  although  it  is  not  uncommon  in  adolescence  or  even  early 
adult  life.  This  is  illustrated  by  the  statistics  of  the  recent  epidemic 
in  New  York. 


Under  1  year    . 

1  and  over,  but  under 

2  and  over,  but  under 

3  and  over,  but  under 

4  and  over,  but  under 

5  and  over,  but  under 

6  Eftid  over,  biit  under 

7  and  over,  but  under 

8  and  over,  but  under 

9  and  over,  but  under  10 
10  and  over,  but  under  11 
11-15,  but  under  16 

16  and  over  .... 


Totals. 

751 

2 1,541 


1,714 
1,278 
618 
511 
304 
184 
130 
126 
68 
142 
129 


7,496 

Summary.  , 

Under  1  year 10.0  per  cent. 

Under  3  years .       .  53.9    " 

1  year  and  over,  but  under  6  years 75 . 0    " 

6  years  and  over,  but  under  11  yeai's 10.8    " 

11  years  and  over,  but  under  16  years       .      ;      .      .      .      .  1.9    " 

16  years  and  over ' 1.7" 


In  both  endemic  and  epidemic  forms  it  is  far  more  common 
during  the  warm  months  than  at  other  seasons,  as  is  illustrated  by 
the  following  tables.'  - 

January 16 

February     9 

March 25 

April 14 

May 24 

June 62  "i  466,  or  68  per  cent., 

July 133  [      during     the     four 

August 159  {      months,    June    to 

September 112  J       September. 

October 81 

November 40 

December 4 


State  of  New  York. 


679 


Deaths. 

June 367  64 

July       .      .      .      ,■ 4,011  895 

August 5,987  1,466 

September 1,992  628 

October 645  215 

November         135  40 

December 40  22 

Total 13,177  3,330 

1  Jour.  Am.  Med.  Assn.,  November  14,  1908. 

2  Nicoll:  New  York  State  Jour,  of  Med.,  June,  1917. 


Fatality 

rate  per 

100  Cases. 

17.4 

22.3 

24.5 

31.5 

33.3 

29.6 

50.6 

25.1 


612  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  epidemics  the  mortality  is  much  higher  than  under  ordinary 
conditions.  In  five  years,  1905-1909,  7103  cases  were  reported  in 
New  York  City  with  538  deaths,  7.4  per  cent.  In  the  recent  epidemic 
there  were  2414  deaths  in  a  total  of  8991  cases,  27.2  per  cent.  In 
the  remainder  of  the  State  there  were  866  deaths  in  4186  cases,  21.1 
per  cent.  The  mortality  among  males  was  50  per  cent,  higher  than 
among  females.  In  epidemics  there  are  many  abortive  cases  in  the 
sense  that  paralysis  does  not  follow,  as  in  14  per  cent,  of  the  cases 
reported  by  Wickman,^  and  there  are  others  in  which  the  paralysis 
is  transitory,  as  in  about  20  per  cent,  of  the  cases  in  the  New  York 
epidemic. 

Distribution  of  the  Paralysis. — The  lower  extremities  are  far  more 
often  paralyzed  than  the  upper.  In  1765  of  2418  cases  reported  by 
various  writers  the  persistent  paralysis  was  limited  to  the  lower 
extremities,  as  compared  with  195  cases  in  which  the  upper  extremi- 
ties were  alone  involved. 

The  general  distribution  was  as  follows : 

One  leg 1120 

Both  legs 645 

One  arm 162 

Both  arms 33 

Leg  and  arm 222 

Three  extremities 42 

All  extremities   . 194 

2418 

In  general  it  may  be  stated  in  regard  to  persistent  paralysis  that 
the  upper  arm  muscles  are  more  often  involved  than  the  lower. 
The  anterior  thigh  muscles  far  more  often  than  the  posterior.  The 
anterior  leg  group  far  more  often  than  the  posterior  and  the  adductor 
muscles  of  the  foot  than  the  abductor.  The  tensor  vaginse  femoris 
muscle  and  the  short  flexors  of  the  toes  most  often  retain  power 
when  the  paralysis  is  extensive.  The  spinal  and  abdominal  groups 
are  often  weakened  or  paralyzed  at  the  onset  of  the  disease,  but 
recovery  in  the  cases  of  ordinary  severity  is  the  rule. 

In  a  total  of  500  personal  cases  examined  from  two  to  three 
months  after  the  onset  of  the  disease  the  abdominal  muscles  were 
partially  or  completely  paralyzed  in  50. 

Tabulations  are  only  approximately  correct,  since  complete 
paralysis  of  one  extremity  is  often  accompanied  by  temporary  or 
persistent  weakness  of  the  other. 

The  Committee  on  Poliomyelitis  of  the  Conference  of  State  and 
Provincial  Boards  of  Health  (April  30,  1917),  from  an  examination 
of  the  reports  of  various  epidemics,  concludes  that  the  incubation 
period  varies  from  fom'  to  fourteen  days,  but  is  commonly  seven 

1  Ztschr.  f.  klin.  MecL,  1907,  No.  63. 


ACUTE  ANTERIOR  POLIOMYELITIS  613 

daySj  that  poliomyelitis  is  widely  prevalent,  but  is  generally  of  the 
non-paralytic  type,  and  that  the  disease  is  transmitted  chiefly  by 
contact  with  a  patient  or  carrier.  The  committee  suggested  cer- 
tain minimum  requirements  for  the  control  of  the  disease,  as  follows: 

1.  That  an  isolation  period  for  a  patient  of  not  less  than  two 
"  weeks  nor  more  than  three  weeks  from  onset  be  required  unless 

the  temperature  has  not  returned  to  normal  in  the  meantime. 

2.  That  children  of  the  same  household  in  contact  with  a  patient 
be  excluded  from  places  of  public  assembly  for  a  period  of  fourteen 
days  from  the  last  date  of  contact  as  determined  by  the  health  officer. 

3.  That  an  adult  of  the  household,  if  the  patient  is  properly 
isolated,  may  continue  his  vocation,  provided  it  does  not  bring  him 
into  contac"*  with  children  at  any  time. 

Disinsection. — (1)  the  discharges  from  the  nose,  throat  and  bowels 
of  the  patient  be  disinfected  promptly;  (2)  the  caretaker  shall  wash 
her  hands  with  soap  and  hot  water  promptly  after  handling  said 
discharges;  (3)  the  caretaker  shall  wash  her  hands  similarly  before 
leaving  the  room  occupied  by  the  patient;  (4)  isolation  shall  be 
terminated  by  a  thorough  washing  of  entire  body  and  hair  of  the 
patient  and  the  room  cleaned  with  soap  and  hot  water,  aired  and 
sunned;  (5)  sick-room  precautions  should  include  the  usual  atten- 
tion to  cleaning  and  disinfection  of  eating  utensils,  personal  and 
bedclothing,  rugs,  door-knobs  and  other  things  handled  by  the 
patient  or  caretaker. 

Symptoms. — The  disease  and  its  effects  may  be  divided  into 
several  stages: 

1.  The  stage  of  onset.  This  is  usually  attended  by  constitutional 
symptoms,  by  fever,  headache  and  drowsiness;  by  vomiting  and 
intestinal  disturbance,  by  sweating  and  stiffness  of  the  neck  muscles, 
and  occasionally  by  severe  pain  in  the  back  or  limbs  explained 
according  to  Flexner  by  involvement  of  the  intervertebral  ganglia. 
In  many  instances  the  elevation  of  the  temperature  is  not  extreme, 
nor  is  the  constitutional  disturbance  severe,  and  but  for  the  paralysis 
the  attack  would  be  considered  as  one  of  the  ordinary  illnesses  so 
common  in  childhood.  In  some  cases,  however,  the  fever  is  high, 
and  there  may  be  convulsions,  delirium,  and  prolonged  uncon- 
sciousness, while  in  others  there  may  be  no  premonitory  symptoms 
whatever;  the  child,  apparently  well  at  night,  wakens  in  the  morn- 
ing paralyzed. 

In  many  instances  the  weakness  or  paralysis  caused  by  anterior 
poliomyelitis  of  a  mild  type  in  infancy  is  not  discovered  until  the 
child  begins  to  walk,  when  the  awkward  gait  or  limp,  or  the  distor- 
tion of  a  foot,  may  make  it  evident. 

In  a  few  hours  or  a  few  days  after  the  first  symptoms  of  the  dis- 
ease the  paralysis  appears  or  is  detected,  its  area,  corresponding  in 
some  degree  to  the  severity  of  the  symptoms,  may  extend  slowly 


614  DISEASES  OF   THE  NERVOUS  SYSTEM      ' 

after  it  is  recognized,  or  its  extreme  limit  may  be  reached  at  once. 
The  primary  paralysis  is  always  greater  than  that  which  finally 
persists.  The  duration  of  the  acute  stage  of  the  disease  is  about  a 
week. 

There  are  several  types  of  the  disease  corresponding  to  the 
symptoms  or  the  distribution  of  the  paralysis. 

(a)  The  abortive,  in  which  the  constitutional  symptoms  are  not 
follow'ed  by  paralysis. 

(b)  The  ordinary  spinal  type. 

(c)  An  ascending  or  descending  form  that  spreads  gradually, 
often  involving  the  muscles  of  respiration. 

(d)  The  bulbar  type,  in  which  cranial  nerves  are  in^'olved. 

(e)  The  cerebral  t^pe,  affecting  the  cerebral  cortex  and  inducing 
increased  reflexes. 

(/)  The  meningeal  form,  involving  chiefly  the  pia  mater  and  in 
which  the  s\Tnptoms  resemble  those  of  cerebrospinal  meningitis. 

2.  Then  follows  a  stationary  period,  lasting  from  a  week  to  a 
month;  the  constitutional  symptoms  cease  but  the  paralysis  persists. 

3.  This  is  succeeded  by  the  stage  of  partial  recovery,  lasting 
from  one  to  six  months  or  longer.  The  muscles  which  were  par- 
alyzed because  of  the  secondary  congestion  and  exudation  about 
the  local  myelitis  recover  their  power  in  whole  or  in  part,  w'hile 
those  muscles  supplied  from  the  area  in  the  cord  in  which  the  nerve 
cells  have  been  destroyed  waste  away.  At  this  time  the  contrac- 
tions and  distortions  in  the  paralyzed  limbs  develop. 

4.  The  chronic  stage.  This  may  be  considered  from  the  thera- 
peutic stand-point  to  last  until  adult  age  or  until  the  ultimate  effect 
on  the  individual,  due  to  the  retardation  of  the  growth  and  unbal- 
ancing of  the  mechanical  equilibrimn  of  the  body,  may  be  complete. 

The  sensation  of  the  paralyzed  part  is  not  affected  except  in  the 
extreme  cases.  The  temperature  is  lower  from  the  first.  In  many 
instances  the  limb  is  not  only  cold,  but  it  is  congested  and  "blue." 
These  circulatory  disturbances  are  caused  primarily  by  the  inter- 
ference with  the  vasomotor  function,  but  they  are  confirmed  later 
by  the  atrophy  of  the  muscles  and  by  the  permanent  contraction 
of  the  bloodvessels.  Thus,  in  general,  the  impairment  of  the  circu- 
lation corresponds  to  the  degree  of  the  paralysis,  but  not  absolutely 
so.  In  certain  cases  the  paralysis  may  be  limited  in  extent,  and 
yet  the  limb  may  be  cold  and  congested,  while  in  others  in  which 
the  loss  of  power  is  much  greater  the  temperature  is  but  slightly 
lowered  and  the  color  remains  normal.  The  same  is  true  of  retarda- 
tion of  growth.  In  most  instances  the  ultimate  shortening  of  the 
limb  corresponds  to  the  degree  of  the  paralysis  and  consequent  loss 
of  function;  but  occasionally  cases  are  seen  in  which  the  groT^lh  is 
markedly  retarded,  although  but  few  of  the  muscles  are  paralyzed. 

Diagnosis. — The  diagnosis  of  acute  anterior  poliomyelitis  is  not 
usually  made,  except  in  epidemics,  before  the  stage  of  paralysis.    An 


ACUTE  ANTERIOR  POLIOMYELITIS  615 

increase  of  intraspinal  pressure  and  an  increase  in  the  number  of 
cells  in  the  fluid  being  the  most  significant  signs.  But  after  the 
paralysis  has  appeared  there  should  be  little  difficulty  in  interpret- 
ing the  symptoms.  It  is  a  disease  usually  of  acute  onset,  followed 
by  paralysis  of  certain  muscular  groups  or  of  entire  members.  It  is 
a'flaccid  paralysis,  the  reflexes  are  lost,  the  muscles  no  longer  con- 
tract under  faradism,  and  the  reaction  of  degeneration  soon  appears; 
the  tissues  waste,  and  the  circulation  is  impaired  in  the  affected 
parts. 

It  is  usual  to  consider  first  in  differential  diagnosis  the  paralyses 
of  cerebral  origin,  but  this  is  more  for  the  purpose  of  calling  attention 
to  the  essential  differences  between  the  two  than  because  they  are 
likely  to  be  confounded  by  one  acquainted  with  the  ordinary  char- 
acteristics of  cerebral  and  spinal  disease. 

Paralysis  of  Cerebral  Origin  in  Childhood. — ^The  common  form  is 
hemiplegia.  It  is  often  congenital,  the  result  of  injury  at  birth, 
and  the  intelligence  may  be  impaired.  The  paralysis  is  not  com- 
plete, nor  is  it  limited  to  groups  of  muscles;  it  is  rather  powerless- 
ness  or  impairment  of  function,  due  to  loss  of  cerebral  control.  The 
reflexes  are  increased  and  limbs  are  stiffened,  not  flaccid.  The 
electrical  reactions  are  not  lost  or  changed  in  quality.  Paralysis  of 
cerebral  origin  may  be  also  paraplegic  or  diplegic  in  its  distribution, 
but  in  these  cases  the  general  characteristics  are  the  same  as  in  the 
hemiplegic  form,  except  that  the  intelligence  is  more  markedly 
affected . 

Other  Forms  of  Spinal  Paralysis.— Transverse  myelitis  is  very 
uncommon  in  childhood.  In  this  disease  the  distribution  is  equal, 
the  reflexes  are  at  first  increased,  and  sensation  as  well  as  motion 
is  lost. 

Pott's  Paraplegia. — In  this  form  of  paralysis,  also,  the  distribution 
is  equal,  the  reflexes  are  increased,  and  the  signs  of  the  disease  of 
the  spine  are  always  present. 

Spastic  Spinal  Paraplegia. — In  this  as  in  the  preceding  form  the 
distribution  is  equal,  and  the  reflexes  are  exaggerated. 

Rheumatism  and  Joint  Disease. — ^In  orthopedic  practice  anterior 
poliomyelitis  is  not  often  seen  in  the  stage  of  onset  unless  pain  is  a 
prominent  symptom,  when  the  disease  may  be  mistaken  for  rheu- 
matism or  for  some  form  of  joint  disease.  Cases  of  this  type  are 
not  uncommon.  The  tissues  are  sensitive  to  pressure  and  the  move- 
ments of  the  joints  cause  discomfort.  In  certain  instances  the 
paralysis  may  not  be  apparent  on  the  first  examination;  when  it 
does  appear  the  diagnosis  is,  of  course,  established;  therefore  the 
characteristics  of  diseases  of  the  joints  need  not  be  detailed. 

Multiple  Neuritis.— Multiple  neuritis  is  usually  a  sequel  of  infec- 
tious diseases,  or  of  metaUic  poisoning.  In  the  cases  due  to  metallic 
poisoning  with  lead  or  arsenic  the  paralysis  usually  begins  in  the 
extensors  of  the  hands  and  feet,  and  is  symmetrical  in  its  distribu- 


616  DISEASES  OF   THE  XERVOUS  SYSTEM 

tion.  This  is  true,  also,  of  the  localized  forms  of  paralysis  following 
contagious  diseases  in  which  the  dorsal  flexors  of  the  feet  are  most 
often  invoh'ed.  In  multiple  neuritis  there  is  visually  local  sensitive- 
ness lasting  a  longer  time  than  in  poliomyelitis;  the  paralysis  is 
gradual  in  its  onset,  and  sensation  as  well  as  motion  is  affected. 

Diphtheritic  Paralysis. — Diphtheria  is  the  most  common  cause  of 
general  weakness  terminating  in  paralysis,  but  in  these  cases  there  is 
usually  a  history  of  the  preceding  disease.  The  paralysis  appears 
first  in  the  muscles  of  the  throat  and  neck,  and  a  general  and 
increasing  weakness  precedes  by  a  considerable  interval  the  com- 
plete loss  of  power. 

Weakness.  Pseudoparalysis. — Weakness  caused  by  rhachitis,  the 
so-called  pseudoparalysis,  due  to  this  or  to  other  affections,  is 
readily  distinguished  from  actual  paralysis  by  pricking  the  part  with 
a  pin,  when  muscular  contraction  and  movement  of  the  limb  will 
be  evident.  This  test  of  function  is  of  value  in  showing  the  distri- 
bution of  actual  paralysis.  Loss  of  power  in  the  tibialis  anticus 
muscle,  for  example,  causes  valgus  resembling  closely  the  ordinary 
valgus  due  to  simple  weakness.  In  simple  weakness  the  child  with- 
draws the  foot  from  the  point  of  the  pin,  and  the  ability  to  move  it 
in  all  directions  is  very  evident;  but  if  the  tibialis  anticus  muscle  is 
paralyzed  the  foot  is  always  flexed  m  the  abducted  attitude.  The 
same  test  may  be  made  for  paralysis  of  other  muscles  or  muscular 
groups.  It  is  a  test  that  is  easily  applied  and  that  is  especially 
useful  in  the  examination  of  young  children. 

Obstetrical  Paralysis. — Paralysis  of  the  arm  due  to  anterior 
poliomyelitis  is  infrequent  as  compared  with  that  of  the  lower 
extremity.  This  form  might  be  mistaken  for  obstetrical  paralysis, 
but  the  history  of  the  disability  and  its  distribution  should  make 
the  diagnosis  clear. 

Prognosis. — The  prognosis  as  to  function  depends  primarily 
upon  the  area  of  the  destructive  disease  of  the  cord,  secondarily 
upon  the  treatment  of  the  weakened  or  disabled  part.  As  has  been 
stated,  the  extent  of  the  primary  paralysis  is  very  much  greater 
than  that  which  ultimately  persists. 

The  Electrical  Test. — During  the  early  stages  of  the  disease  the 
extent  of  the  residual  paralysis  may  be  estimated  with  some  degree  of 
accuracy  by  the  electrical  reaction.  ^Yithin  a  week  after  the  initial 
paralysis  the  reaction  to  the  faradic  current  in  the  muscles  and  nerves 
in  direct  connection  with  the  diseased  area  is  lessened  and  is  soon 
lost.  If  the  faradic  irritability  is  retained  in  the  paralyzed  muscles, 
or  if  it  is  merely  diminished,  recovery  may  be  predicted.  The 
muscles  which  no  longer  react  to  the  faradic  irritation  may  still  be 
made  to  contract  by  the  galvanic  current.  In  normal  muscles  the 
reaction  is  greatest  at  the  closing  of  the  negative  pole.  In  the  par- 
alyzed muscles  the  reaction  is  slower,  it  requires  stronger  stimula- 
tion, and  the  contraction  is  greater  at  the  closing  of  the  positive 


ACUTE  ANTERIOR  POLIOMYELITIS  617 

pole.  This  is  known  as  the  reaction  of  degeneration.  The  loss  of 
faradic  reaction  and  the  change  in  the  galvanic  reaction  indicate 
that  the  function  of  the  affected  muscle  will  be  seriously  impaired, 
although  certain  of  its  fibres  may  in  time  regain  their  power. 

It  must  be  borne  in  mind  that  the  paralysis  of  anterior  poHo- 
myelitis  is  in  general  incomplete,  that  a  certain  proportion  of  the 
muscular  substance  of  an  apparently  paralyzed  muscle  may  remain 
active,  indicating  similar  activity  of  the  nerve  cells  in  the  spinal  canal 
and  capable  possibly  of  further  development.  Also,  that  the  num- 
ber of  i^erve  cells  in  adult  life  is  double  that  at  birth,  indicating  a 
possibility  of  further  regeneration. 


Fig.  473. — Anterior  poliomyelitis.     Extreme  flexion  deformity  at  the  hips,  inducing 
quadrupedal  locomotion.     (Gibney.) 

The  Effects  of  Paralysis  of  Different  Muscles  and  Groups  of  Muscles 
upon  Function. — The  principal  interest  in  anterior  poliomyelitis  lies 
in  its  immediate  and  ultimate  effects  upon  the  functional  ability 
of  the  individual.  These  effects  may  be  classified  as  deformity  of 
the  part  directly  involved  and  the  influence  of  weakness,  deformity,  and 
loss  of  growth  upon  the  body  as  a  whole. 

Causes  of  Deformity. — ^The  deformities  of  anterior  poliomyelitis 
^.pe  caused: 

1.  By  force  of  gravity. 
;    2.  By  the  unopposed  action  of  the  active  muscles. 

3.  By  habitual  posture. 

4.  By  functional  use. 


618 


DISEASES  OF   THE  XERVOUS  SYSTEM 


All  these  and  other  less  miportant  causes  of  deformity  are,  of 
course,  combmed  in  most  instances.  The  relative  importance  of 
each  factor  varies,  according  to  the  muscular  group  that  is  involved, 
Avith  the  age  of  the  patient,  and  with  the  strain  to  T\'hich  the  part  is 

subjected.  The  uifluence  of 
the  different  factors  can  be 
studied  best  in  the  foot. 

Muscular  Action  and  Gravity. 
— In  by  far  the  larger  number 
of  cases  one  or  more  of  the 
dorsal  flexors  of  the  foot  are 
involved.  This  is  illustrated  by 
the  statistics  of  acquired  tali- 
pes, tabulated  elsewhere,  the 
equinus  t\'\:>e  of  deformity  being 
three  times  as  common  as  the 
calcaneus  form. 

If  the  anterior  muscles  are 
paralyzed  be'fore  the  walkmg 
age,  the  foot  drops  under  the 
influence  of  the  force  of  gravity 
into  the  attitude  of  equinus. 
If  this  attitude  is  allowed  to 
persist,  the  muscles  on  the  pos- 
terior aspect  of  the  limb,  ac- 
commodating themselves  to  the 
habitual  attitude  become  struc- 
turally shortened.  In  such  cases 
the  equinus  deformity  is  caused 
by  the  force  of  gravity;  it  is 
mcreased  by  unopposed  muscu- 
lar action  and  it  is  fixed  by 
muscular  shortening  in  adapta- 
tion to  the  persistent  attitude. 
That  deformity  is  not  caused 
du'ectly  by  muscular  action  is 
shown  by  the  fact  that  it 
may  be  prevented  by  system- 
atic passive  movements  to  the 
limit  of  dorsal  flexion.  Deformity  is  thus  prevented,  not  by  oppos- 
ing muscular  action,  but  by  stretching  the  active  muscles  to  the  full 
limit  and  thus  preventing  muscular  adaptation  and  structural 
change.  In  the  instance  cited  gravity  and  muscular  activity  are 
combined  in  the  production  of  deformity,  but  in  other  instances 
gravity  and  muscular  power  may  be  opposed  to  one  another.  If, 
for  example,  the  calf  muscle  is  paralyzed  while  the  anterior  group 
retams  its  power,  the  characteristic  deformity  of  calcaneus  opposed 


Fig.  474. — Anterior  poliomyelitis.  After 
seven  years.  Showing  atrophy  and  slight 
lateral  curvature  of  the  spine;  two  and 
a  quarter  inches  of  shortening. 


ACUTE  ANTERIOR  POLIOMYELITIS 


619 


by  the  force  of  gravity  does  not  usually  appear  until  the  child  begins 
to  use  the  foot,  when  the  peculiar  helplessness  calls  attention  to  the 
disability,  if  the  diagnosis  has  not  been  made  before.  Thus  it  is 
that  equinus  may  be  present  when  the  child  is  still  in  arms,  while 
the  opposite  deformity  develops  much  more  slowly. 

Habitual  Posture. — There  are  other  cases  in  which  every  vestige 
of  muscular  power  is  lost  and  the  foot  "dangles"  on  the  leg.  In  this 
class  there  is  no  functional  activity  or  tonic  contraction  of  the  muscles ; 
consequenth"  deformity  is  slow  in  making  its  appearance;  it  is  not 
often  extreme,  and  it  becomes  fixed  only  by  the  structural  shortening 
of  inactive  tissues,  the  ligaments,  fascise,  and  the  atrophied  muscles. 


Fig.  475. — Paralytic  dislocation  of  the  hip. 

There  are,  of  course,  other  causes  for  habitual  posture  than  the  force 
of  gravity  and  muscular  action,  such  as,  for  example,  the  position 
of  convenience  in  which  a  weak,  or  disabled  or  sensitive  part  might  be 
placed.  For  example,  in  extensive  paralysis  of  the  lower  extremi- 
ties the  habitual  sitting  posture  requires  flexion  at  the  hips  and  knees, 
and  contractions  at  these  joints  soon  appear  unless  they  are  pre- 
vented, especially  in  those  cases  in  which  the  residual  muscular 
activity  favors  the  deformity. 

Functional  Use  as  a  Cause  of  Deformity. — Thus  far  the  force  of 
gravity,  habitual  posture,  unbalanced  muscular  power,  and  the 
structural  changes  in  the  tissues  have  been  considered  in  the  etiology 


620  DISEASES  OF   THE  XERVOUS  SYSTEM 

of  deformity  as  it  might  develop  in  infancy.  When,  howe^'er,  the 
patient  stands  and  \A-alks,  existing  deformities  are  exaggerated  and 
confirmed  by  the  weight  of  the  body  falhng  on  the  unbalanced  part, 
and  by  the  action  of  the  muscles  in  the  attempt  to  supply  the  func- 
tion of  those  that  are  paralyzed.  Thus  it  is  that  the  deformity 
develops  far  more  rapidly  when  a  fan*  amount  of  muscular  power 
remains  than  when  it  is  completely  lost.     (See  Talipes.) 

Subluxation. — Aside  from  the  distortions  due  to  the  causes  that 
have  been  mentioned,  there  are  others  induced  simply  by  weakness; 
for  example,  laxity  of  ligaments  and  the  want  of  muscular  support 
may  permit  distortion  of  a  limb  and  subluxation  or  even  dislocation 
of  a  joint  (Figs.  476  and  477).  Complete  displacement  is  uncom- 
mon, and  occurs  practically  only  at  the  hip.  In  such  cases  there  is 
usually  flexion  deformity  of  the  limb,  the  femur  being  suspended  by 
the  contracted  tissues  attached  to  the  anterosuperior  spine.  This 
unyielding  band  forms  a  fulcrum  by  means  of  which  force  applied 
at  the  knee  may  cause  sudden  displacement  of  the  head  of  the 
femur  forward  or  upward  and  backward  (Fig.  475). 

Deformities  of  the  Upper  Extremity. — Deformities  caused  by  paraly- 
sis of  the  muscles  of  the  shoulder  are  usually  slight  because  the  part 
is  not  subjected  to  the  strain  of  weight-bearing,  and  because  the 
force  of  gravity  is  opposed  to  muscular  contraction.  In  these  cases 
the  loss  of  muscular  support  and  the  resulting  tension  on  the  capsule 
allow  a  considerable  separation  of  the  joint  surfaces  so  that  the 
atrophied  head  of  the  humerus  may  be  displaced  forward  or  back- 
ward; but  there  is  not  often  fixed  displacement,  and  consequently 
persistent  distortion  due  to  this  cause  is  unusual.  Abduction  and 
rotation  are  sometimes  limited  by  muscular  resistance  or  by 
accomodation  to  habitual  posture. 

Paralysis  of  the  muscles  of  the  forearm  and  of  the  hand  is  followed 
after  a  time  by  deformity  of  the  fingers,  caused  primarily  by  unop- 
posed muscular  action,  secondarily  by  accommodation  and  atrophy. 

Deformities  of  the  Neck. — Paralysis  of  one  or  more  of  the  muscles 
of  the  neck  may  induce  a  paralytic  torticollis.  This  is,  however, 
uncommon. 

Deformities  of  the  Trunk. — Distortions  of  the  trunk  are  usually 
induced  by  habitual  posture  during  the  early  stages  of  the  disease 
when  the  paralysis  is  widespread,  particularly  when  the  abdominal 
muscles  are  involved,  and  persist  even  though  the  muscles  recover 
then  strength  in  whole  or  part.  The  direct  effect  of  paralysis  of 
the  trunk  muscles  in  inducing  lateral  curA'ature  in  the  thoracic 
region  is  not  usually  as  might  at  first  appear,  the  miopposed 
action  of  the  active  muscles  and  thus  a  bending  of  the  trunk 
with  a  com'exity  toward  the  weaker  side.  As  a  rule  the  curvature 
is,  as  a  whole,  in  the  opposite  direction.  This  is  explained  by  the 
fact  that  if  the  paralysis  is  limited  to  one  side  and  is  extensive 
enough  to  cause  distortion  of  the  trunk,  the  muscles  of  respiration 


ACUTE  ANTERIOR  POLIOMYELITIS 


621 


being  involved,  the  chest  wall  becomes  inactive  and  collapses.     In 
compensation  the   opposite   side   of   the  thorax    increases  in  size 


Fig.  476. — Anterior  poliomyelitis,  causing  genu  recurvatum.     (See  Fig.  477.) 


F1G.J477. — Anterior  poliomyelitis.     Paralysis  of  muscles  at  the  hip  permits  subluxa- 
tion of  the  femur.     The  same  patient  as  in  Fig.  476. 


622 


DISEASES  OF   THE  NERVOUS  SYSTEM 


and  lung  capacity  and  the  weak,  atrophied,  and  sunken  side  is 
drawn  toward  it.  The  same  effect  is  observed  when  the  arm  and 
the  shoulder  muscles  are  paralyzed,  the  spine  bending  toward 
the  side  that  is  still  active.  The  convexity  of  primary  lumbar 
curvature,  however,  is  usually  toward  the  weak  or  paralyzed  muscles 
and  is  induced  more  directly  by  activity  of  the  stronger  trunk  or 
abdominal  groups. 

Paralysis  of  the  posterior  group  of  muscles,  if  extreme,  may 
induce  kyphosis.  Paralysis  of  the  muscles  of  the  abdomen  causes 
lordosis  when  the  erect  posture  is  resumed,  but  in  this  group  of 

cases  the  lower  extremities  are  us- 
ually involved,  and  the  secondary 
distortions  due  to  posture  and  to 
functional  use  mask  the  direct  effect 
of  the  paralysis  of  the  muscles  of  the 
trunk.  And,  again,  the  overuse  of 
the  arm  muscles  in  patients  whose 
lowerextremities  are  paralyzed,  and 
the  suspension  of  the  body  on 
crutches  in  walking,  modify  the 
ultimate  effects  in  those  cases  in 
which  the  paralysis  is  widespread  in 
its  area.  (See  Lateral  Curvature.) 
Retardation  of  Growth  and  Sec- 
ondary Deformities. — The  effects  of 
anterior  poliomyelitis  are  not  lim- 
ited to  the  paralysis  and  to  atrophy 
of  the  muscles,  but  all  the  com- 
ponent tissues  of  the  affected  limb 
are  involved  as  well.  The  bones 
become  relatively  atrophied,  and 
their  growth  is  retarded  to  a 
degree  fairly  proportionate  to  the 
extent  of  the  paralysis  and  to 
the  functional  disability  that  has 
resulted.  As  has  been  stated,  retar- 
dation of  growth  does  not  always 
correspond  to  the  degree  of  paralysis.  In  some  instances  paralysis 
of  a  single  muscle,  which  does  not  seriously  compromise  the  function 
of  the  part,  is  accompanied  by  greater  shortening  of  the  limb  than 
in  other  cases  in  which  the  paralysis  is  far  more  extensive.  Thus 
it  may  be  inferred  that  certain  cells  in  the  spinal  cord  are  especially 
concerned  in  the  growth  and  nutrition  of  the  bones  and  that  inter- 
ference with  the  function  of  these  cells  may  not  correspond  abso- 
lutely to  the  extent  of  the  destructive  process.  However  this  may 
be,  it  is  certain  that  atrophy  and  retardation  of  growth  are  much 
greater  when  a  limb  is  not  used  than  when  by  the  aid  of  apparatus 


Fig.  478. — The  preventable  deform- 
ities of  anterior  poliomyelitis. 


t    t 


ACUTE  ANTERIOR  POLIOMYELITIS 


623 


it  has  been  enabled  to  carry  out.  in  part  at  least,  its  proper  function. 
It  is  evident,  also,  that  retardation  of  growth  will  be  more  marked 
during  the  period  of  rapid  development;  thus  the  younger  the 
patient  the  greater  should  be  the  ultimate  inequality  of  the  limbs. 

Retardation   of   Growth. — ^The   ultimate    shortening    varies 
from  one  to  three  or  more  inches.     In  the  slighter  degrees  of  paralysis 


Fig.  479. — Resistant  coDtractions  at  the  hips,  knees  and  ankles  eight  weeks 
after  the  onset  of  the  disease.      (See  Fig.  480.) 

affecting  the  leg  the  shortening  may  be  less  than  an  inch,  but  when 
the  thigh  muscles  are  paralyzed  also  it  may  be  much  more  (Fig. 
474).    This  inequality  is  usually  noticeable  in  the  feet. 

When  both  limbs  are  paralyzed,  so  that  locomotion  is  very 
seriously  interfered  with,  the  retardation  of  growth  is  especially 
marked,  and  the  contrast  between  the  trunk  of  the  patient  and  the 
attenuated  lower  extremities  is  verv  striking. 


Fig.  480. — Deformities  corrected  under  anesthesia.     (See  Fig.  479.) 


Compensatory  Distortions. — Secondary  deformities  must 
include,  besides  those  already  mentioned,  the  compensatory  dis- 
tortions of  the  trunk  that  may  follow  paralysis  of  the  limbs.  Thus 
a  shortened  limb  and  the  weakness  of  the  hip  and  thigh  muscles 
might  cause  a  lateral  curvature  of  the  spine,  or-flistion  contragtion  of 


624  DISEASES  OF   THE  NERVOUS  SYSTEM 

the  thigh  might  induce  persistent  lordosis.  In  fact,  the  final  effects 
of  disabihties  of  this  character  are  very  complex,  and  are  influenced 
by  many  factors  of  which  only  a  general  indication  is  practicable. 

Treatment. — ^The  treatment  of  the  acute  stage  of  anterior  polio- 
myelitis is  s}Tnptomatic.  If  the  diagnosis  has  been  made  early, 
such  measures  as  would  tend  to  relieve  the  congestion  about  the 
diseased  area  may  be  employed;  the  first  indication  being  free 
catharsis  and  the  cleansing  of  the  throat  and  nasal  passages.  The 
only  drug  for  which  any  influence  on  the  disease  has  been  claimed 
is  urotropin  in  doses  of  from  5  to  10  grains  three  times  daily. 

Lmnbar  puncture  for  the  relief  of  tension  is  of  apparent  value, 
and  the  injection  of  serum  from  the  blood  of  those  who  have  had  the 
disease  into  the  spinal  canal  may  be  of  service  if  administered 
early.  During  the  active  stage  complete  rest  and  quiet  are  indi- 
cated.    In  cases  in  which  the  paralysis  is  widespread  and  in  which 


Fig.  481. — The  stretcher  frame  as  used  in  cases  of  extensive  paralysis  of  the 

trunk  muscles. 

movements  of  the  limbs  cause  discomfort,  particularly  if  the  skin 
is  hyperasthetic,  a  single  or  double  long  spica  plaster  splint  or 
stretcher  frame  may  be  used  to  support  the  spine  and  extremities. 
When  the  acute  symptoms  have  subsided  local  treatment  to  main- 
tain as  far  as  possible  the  nutrition  of  the  muscles,  to  prevent 
deformity  and  to  relieve  the  strain  upon  the  weakened  tissues,  is 
indicated.  The  nutrition  of  the  parts  may  be  improved  by  friction 
and  gentle  massage,  by  the  direct  application  of  heat  to  the  cold 
extremities,  and  particularly  by  warm  baths.  Galvanism  may  be  of 
direct  service  as  long  as  it  will  induce  contraction  of  the  paralyzed 
muscles  and  indirectly  as  a  stimulant  of  the  nutrition. 

The  most  important  part  of  the  treatment  is  the  prevention  of 
deformity  which  is  otherwise  an  ine^'itable  consequence  of  the 
disease.  In  all  cases  in  which  the  muscles  of  the  trunk  are  involved 
prolonged  rest  on  the  back  is  indicated,  preferably  on  the  stretcher 
frame.  The  sitting  posture  permitted  while  the  muscles  are  weak 
is  the  direct  cause  of  the  great  majority  of  distortions  of  the  spine. 


ACUTE  ANTERIOR  POLIOMYELITIS  625 

The  child  may  be  removed  from  the  frame  at  intervals  for  baths 
and  massage,  and  finally  the  spine  should  be  methodically  stretched 
to  its  normal  limit  in  all  directions  as  soon  as  such  manipulations 
cause  no  discomfort.  By  this  means  and  by  efficient  support 
when  the  erect  posture  is  resumed  lateral  curvature,  the  most  dis- 
astrous of  all  paralytic  deformities,  may  be  prevented. 

In  the  same  manner  deformities  of  the  limbs  may  be  pre- 
vented by  moving  each  joint  to  the  limit  of  the  range  of  motion 
in  all  directions  several  times  a  day,  and  by  supporting  the 
limb  with  simple  apparatus.  Deformity  in  those  parts  in  which 
it  is  favored  by  muscular  action  and  by  the  force  of  gravity 
appears  much  more  rapidly  than  is  generally  supposed.  The  indi- 
cations of  equinus,  for  example,  are  often  apparent  within  a  few 
weeks  after  paralysis  of  the  anterior  muscles  of  the  leg.  The  first 
indication  of  such  deformity  in  this  class  is  the  discomfort  caused 
by  passively  moving  the  foot  toward  dorsal  flexion.  This  limitation 
of  the  range  of  motion  rapidly  increases,  and  as  it  increases  it  is 
confirmed  by  muscular  adaptation  and  finally  by  structural  short- 
ening. This  is  equally  true  of  other  parts  and  much  of  the  pain 
supposed  to  be  hyperesthesia  following  disease  is  actually  caused  by 
tension  on  contracted  tissues.  As  a  rule  the  period  of  rest  during 
the  stage  of  recovery  should  be  prolonged  and  locomotion  should  be 
deferred  as  long  as  possible. 

The  Principles  of  Mechanical  Treatment. — ^The  object  of  a  brace  is 
to  prevent  the  deformity  due  to  weakness  and  to  utilize  the  mus- 
cular power  that  remains,  so  that  the  disabled  member  may  carry 
out  its  function.  As  each  muscle  has  an  essential  function  the 
paralysis  of  any  one  must  be  followed  by  a  certain  disability  and 
usually  by  deformity.  Muscles  vary  in  importance  as  they  do  in 
strength,  and  the  ultimate  disability  caused  by  paralysis  may  be 
predicted  with  accuracy  by  one  who  is  familiar  with  this  func- 
tion. 

Paralysis  of  the  Anterior  Muscles  of  the  Leg. — Paralysis 
of  the  anterior  leg  group  causes  the  so-called  steppage  gait;  the  toes 
drag  on  the  floor  when  the  limb  is  swung  forward,  and  this  necessi- 
tates an  awkward  lifting  of  the  knee.  The  result  of  such  paralysis 
is  equinus.  Slight  equinus  has  a  tendency  to  throw  the  knee  back- 
ward, "recurvatum,"  in  order  that  the  patient  may  place  the  entire 
sole  on  the  ground.  More  marked  equinus  obliges  the  patient  to 
bear  the  weight  entirely  on  the  front  of  the  foot,  and  unless  the  limb 
is  short  usually  induces  flexion  both  at  the  knee  and  hip.  If  but  one 
of  the  dorsal  flexors  is  paralyzed  the  tendency  to  equinus  is  insofar 
lessened,  but  there  is  an  inclination  to  lateral  distortion.  Paraly- 
sis of  the  anterior  muscles  causes  an  awkward  gait  and  often  deform- 
ity, but  the  propelling  force  of  the  limb  remains.  The  indication 
for  support  is  simple,  to  prevent  the  foot  from  dropping  to  the  extent 
that  inconveniences  the  patient. 
40 


626 


DISEASES  OF   THE  NERVOUS  SYSTEM 


Para-lysis  or  the  Posterior  Muscles  of  the  Leg. — If,  on  the 
other  hand,  the  calf  muscle  is  paralyzed  the  resistance  of  the  foot 
is  lost  and  it  is  simply  dorsiflexed  when  weight  is  thrown  upon  it. 
The  gait  is  inelastic  and  awkward.  In  most  instances  other  muscles 
are  paralyzed  also,  so  that  the  foot  is  inclined  laterally.  Thus  the 
brace  must  be  arranged  to  prevent  dorsal  flexion,  and  it  must  be 
strong  enough  to  support  the  strain  which  is  transmitted  from  the 
foot  plate  of  the  brace  to  the  front  of  the  leg.  The  various  weak- 
nesses and  deformities  of  the  foot  and  the  means  of  treating  them 
are  described  at  length  elsewhere.     (See  Talipes.) 

Paralysis  of  the  calf  muscle  not  only  affects  the  foot,  but  it 
weakens  the  knee  as  well  and  hyperextension  or  genu  recurvatum  is 
often  a  secondary  effect.  In  many  instances,  therefore,  it  will  be 
necessary  to  support  the  knee  as  well  as  the  ankle  during  the  earlier 
stages  of  the  treatment. 


Fig.  482. — Postural  deformities.    Lateral  curvature   of  the  spine  and  contractures 
of  the  lower  extremities. 


Paralysis  of  the  Thigh  ]\Iuscles. — Paralysis  of  the  quadriceps 
extensor  muscle  causes  primarily  a  peculiar  gait.  The  patient, 
unable  to  extend  the  leg  upon  the  thigh,  throws  or  swmgs  it  forward, 
then  locks  the  joint  by  direct  contact  of  the  bones  and  by  the  resis- 
tance of  the  posterior  tissues,  by  inclining  the  body  somewhat  for- 
ward as  the  weight  falls  upon  it.  In  this  manner,  again,  the  knee 
may  be  overextended.  Or  if  extension  is  checked  by  shortening  of 
the  tissues,  mduced,  for  example,  by  habitual  assumption  of  the 
sitting  posture,  the  patient  being  unable  to  lock  the  joint  effectively 
by  complete  contact  of  the  bones,  often  trips  and  falls  because  of  the 
insecurity  of  the  support.  AMien  in  the  normal  subject  the  weight 
is  borne  upon  one  limb  in  the  attitude  of  rest,  in  which  the  muscles 


ACUTE  ANTERIOR  POLIOMYELITIS 


627 


are  thrown  out  of  action,  the  knee-joint  is  locked,  but  the  insecurity 
of  this  support  is  illustrated  by  the  school-boy's  trick  of  striking  the 
back  of  the  knee  with  the  hand,  when,  the  muscles  being  taken 
unawares,  the  person  falls  to  the  ground.  This  insecurity  is  con- 
stant when  the  extensor  of  the  leg  is  paralyzed.  For  this  reason 
the  patient  inclines  the  body  forward  and  places  the  hand  on  the 
front  of  the  thigh  in  locomotion. 

Paralysis  limited  to  the  quadriceps  extensor  muscle  is,  however, 
unusual.  In  almost  all  cases  some  of  the  leg  muscles  are  involved, 
also,  and  the  brace  usually  must  serve  to  support  the  foot  as  well  as 
the  knee.     In  its  ordinary  form  such  a  brace  is  constructed  of  two 


Cf^ 


^irla 


Fig.  483  Fig.  484 

Figs.  483   and  484. — The  Judson  brace  for  paralysis  of  the  quadriceps  extensor 

muscle  in  connection  with  deformity  of  the  foot. 


lateral  upright  bars,  reaching  nearly  to  the  pubes  on  the  inner  and 
to  the  trochanter  on  the  outer  side,  joined  to  one  another  by  bands 
passing  beneath  the  thigh  and  the  calf,  and  attached  to  a  light  steel 
foot  plate.  If  the  dorsal  flexors  of  the  foot  are  paralyzed  the  ankle- 
joint  is  arranged  to  allow  dorsal  flexion,  but  to  prevent  extension 
beyond  the  right  angle.  If  the  calf  muscle  is  paralyzed  a  reverse 
catch  is  used,  or  the  uprights  are  attached  directly  to  the  foot  plate 
without  a  joint  (Fig.  484),  or  the  so-called  limited  joint,  allowing 
only  a  few  degrees  of  motion  in  either  direction,  is  used  (Fig.  485). 
(See  Talipes.)  In  the  treatment  of  young  children  the  joint  is  also 
omitted  at  the  knee,  the  limb  being  firmly  held  in  the  extended 


628 


DISEASES  OF   THE  NERVOUS  SYSTEM 


position  during  the  period  of  activity  (Figs.  484  and  487).  This  is  of 
advantage  because  the  joint  is  the  \\'eakest  part  of  the  brace  and  it 
soon  becomes  loose  under  the  severe  strain  to  which  it  is  subjected. 
In  older  subjects  a  joint  is  arranged  with  a  spring  catch,  the  brace 


Fig.  485. — A  brace  for  complete 
paralysis  of  the  limb,  showing  a  form 
of  lock  at  the  knee  and  a  limit'ed  joint 
at  the  ankle. 


Fig.  486. — Anterior  poliomyelitis. 
Paralysis  of  the  anterior  and  posterior 
muscles.     Recur^-ation  of  the  right  knee. 


being  held  in  the  straight  position  vrhen  the  patient  is  walkmg  about, 
but  allowing  flexion  when  the  sitting  posture  is  assiuned.  This  is, 
of  coiu*se,  a  great  convenience  (Fig.  485).  In  fitting  the  brace  the 
lateral  bars  should  be  adjusted  to  support  the  linib  without  uncom- 
fortable pressm-e,  and  the  joints  should  be  exactly  opposite  the 


ACUTE  AXTERIOR  POLIOMYELITIS 


629 


normal  centres  of  motion.  The  thigh  and  leg  bands  should  be 
properly  fitted  to  the  contour  of  the  soft  parts  so  that  half  the  limb 
is  contained  withm  them.  These  are  smoothly  covered  with  leather, 
and  the  limb  is  held  in  position  by  leather  bands  that  complete 
the  circumference.  Other  bands  are  applied  across  the  front  or 
back  of  the  limb,  either  to  support  it  or  to  fix  it  firmly  in  place.  In 
the  ordinary  brace  without  the  joint  at  the  knee  there  are  three 
anterior  bands,  one  across  the  front  of  the  thigh,  another  across  the 
leg,  and  the  third,  a  wide  knee-cap,  supports  the  greater  part  of  the 
strain  (Fig.  487).  The  Thomas  caliper  knee  brace  is  a  light  and 
eftective  appliance  if  no  joints  are  required. 


Fig.  4S7. — Brace  for  complete  paralj-sis  of  the  anterior  muscles  of  the  limb;  before 

and  after  covering. 


Par-ILysis  of  the  Muscles  of  the  Hip. — The  effect  of  paralysis 
of  the  muscles  about  the  hip  is  difficult  to  describe,  as  in  these  cases 
many  other  muscles  are  usually  involved.  If  all  the  muscles  are 
paralyzed  the  thigh  dangles.  This  is,  however,  rather  unusual,  for 
the  tensor  vaginae  femoris  almost  always  retains  its  power  and  it  is 
one  of  the  causes  of  flexion  deformity  which  is  so  often  present  in 
cases  of  this  character. 

Paralysis  of  the  iliopsoas  muscle  makes  it  impossible  for  the 


630 


DISEASES  OF   THE  NERVOUS  SYSTEM 


patient  to  flex  the  thigh  directly  and  in  the  upright  posture  the  body 
is  usuallj"  inchned  somewhat  backward.  Paralysis  of  the  glutei  is 
made  e\'ident  by  the  atrophy  and  by  the  loss  of  the  extending  power 
of  the  limb.  In  walking  the  patient  usually  inclines  the  body 
toward  the  paralyzed  side,  as  if  the  limb  were  shortened. 

The  distribution  of  the 
paralysis  of  the  muscles  of 
the  hip  may  be  ascertained 
by  placing  the  patient  in  the 
recumbent  posture;  the  leg 
is  then  lifted  from  the  table, 
and  by  placing  the  thigh  in 
different  positions  the  ability 
of  the  patient  to  move  it  may 
be  tested,  in  older  subjects 
by  voluntary  effort,  in 
younger  ones  by  pricking 
the  part  slightly  with  a  pin. 
General  weakness  of  the 
muscles  of  the  hip  causes  an 
awkward,  insecure  gait,  ac- 
companied usually  by  out- 
ward rotation  of  the  limb 
which  is  swung  forward  by  a 
rotation  of  the  pelvis.  In 
such  cases  as  has  been  stated, 
there  is  almost  always  ex- 
tensive paralysis  of  other 
muscles  of  the  extremity  and 
a  pelvic  band  must  be  at- 
tached to  guide  the  limb. 
The  pelvic  band  is  made  of 
sheet  steel  of  about  18  gauge, 
two  inches  wide,  fitted  to  the 
pelvis,  which  it  encircles 
midway  between  the  crest  of 
the  ilium  and  the  trochanter. 
At  this  point  it  is  attached 
to  the  brace  by  a  free  joint 
(Fig.  488).  When  the  band 
is  (accurately  [adjusted  and  strapped  firmly  about  the  pelvis  the 
necessary  security  is  assured  and  the  attitude  of  the  limb  in  walk- 
ing can  be  regulated.  If  greater  seciu-ity  is  desired  a  perineal 
band  may  be  applied  as  described  in  the  chapter  on  Disease  of  the 
Hip-joint. 

If  both  limbs  are  paralyzed  double  braces  must  be  used.     If  the 
muscles  of  the  lower  part  of  the  back  are  much  weakened  the  pelvic 


Fig.  488. — Leg  brace,  with  pelvic  band. 
Double  uprights.  No  joint  at  knee.  For 
paralysis  of  the  anterior  tliigh  and  leg  muscles. 


ACUTE  ANTERIOR  POLIOMYELITIS 


631 


For- 


band  may  be  replaced  by  a  corset  or  some  form  of  back  brace, 
timately  these  cases  are  uncommon. 

Paralytic  Scoliosis. — Paralytic  scoliosis  requires  the  support 
of  corsets  or  braces  as  a  rule,  such  as  are  used  in  the  treatment  of 
other  forms  of  distortion  of  the  back.     (See  Lateral  Curvature.) 


Fig.  489.— a  splint  for  paralysis  oi  the  shoulder  and  arm  muscles.      (Gocht.) 


Fig.  490. — A  splint  for  paralysis  of  the  arm  and  hand  muscles.     (Biesalski.) 

Paralysis  of  the  Arm. — Paralysis  of  the  arm  is  comparatively 
uncommon,  and  mechanical  treatment  is  rarely  demanded  except 
during  the  stage  of  recovery. 

If  the  shoulder  muscles  are  paralyzed  the  arm  should  be  supported 
at  the  limit  of  normal  abduction  (Fig.  489),  and  the  other  joints  in 
the  attitudes  that  remove  all  strain  on  the  weak  muscles  (Fig.  490). 


()32  DISEASES  OF   THE  NERVOUS  SYSTEM 

Muscle  Training. — Lovett^  has  called  particular  attention  to  the 
fact  that  paralysis  is  often  partial  rather  than  complete,  and  that 
weak  muscles  may  be  developed  by  appropriate  exercises. 

These  exercises  are  adapted  to  the  weakness  of  the  muscles  and 
are  carried  out  in  attitudes  in  which  they  are  not  antagonized  by 
the  force  of  gravity.  No  resistance  is  used  until  the  full  range  of 
motion  has  been  regained. 

If  possible  the  relative  strength  of  the  weak  muscles  is  tested  by 
a  spring  balance  pulling  against  a  fixed  position  assmned  by  the 
patient,  and  upon  this  basis  the  muscle  training  is  regulated  and 
its  effects  are  judged.  Particular  attention  is  called  to  avoidance 
of  overfatigue  both  in  exercise  and  in  functional  use,  and  upon 
mental  concentration  as  an  aid  in  muscular  control. 

As  the  great  majority  of  cases  are  in  young  children,  the  field  for 
accurate  muscle  testing  is  somewhat  limited,  but  functional  training 
in  some  form  is  possible  in  most  instances.^ 

Operative  Treatment. — ^The  Reduction  of  Deformity. — In  a 
large  proportion  of  the  cases  of  anterior  poliomyelitis  the  patients 
are  not  seen  by  the  orthopedic  surgeon  until  months  or  years  have 
elapsed  since  the  original  attack.  They  are  then  brought  for  treat- 
ment because  of  secondary  deformity,  often  of  an  extreme  degree. 
At  least  half  of  the  cases  of  talipes  are  due  to  this  cause,  and  with  the 
deformity  of  the  foot  are  often  combined  other  distortions  varying 
in  degree  with  the  extent  of  the  paralysis.  Many  of  the  patients 
hobble  about  on  a  distorted  foot,  others  use  crutches,  and  in  a  smaller 
number  the  only  method  of  locomotion  is  creeping  on  all-fours.  In 
the  cases  in  which  the  patient  has  habitually  used  crutches  allowing 
the  paralyzed  limb  to  "dangle,"  there  is  usually  marked  flexion  at 
the  three  joints.  The  thigh  is  flexed  upon  the  pelvis,  the  leg  is 
flexed  upon  the  thigh,  and  the  foot  hangs  downward  and  inward 
(planter  flexed)  in  an  attitude  of  equinovarus. 

However  extreme  the  paralysis  of  a  lower  extremity  may  be,  the 
limb  may  be  made  useful  as  a  prop  when  properly  braced;  this 
prop  will  enable  the  patient  to  dispense  with  the  use  of  crutches 
and  thus  free  the  arms  from  unnecessary  work.  Even  if  both  limbs 
are  paralyzed  they  may  at  least  serve  as  supports  to  enable  the 
patient  to  stand  erect  and  to  propel  himself  with  the  aid  of  crutches. 
If  a  limb  has  been  disused  for  a  long  time,  the  atrophy  is  usually 
extreme,  the  bones  are  fragile,  and  the  growth  has  been  greatly 
retarded  as  compared  with  those  limbs  in  which  deformity  has  been 
prevented  and  in  which  the  weight  of  the  body  has  been  sustained 
in  functional  use.  In  this  class  of  cases  the  first  step  must  be  the 
reduction  of  deformity;  the  foot  must  be  brought  to  a  right  angle 
with  the  leg,  the  limb  must  be  brought  to  the  straight  line,  and  the 

1  Treatment  of  Infantile  Paralysis,  1916. 

2  W.  G.  Wright:  Muscle  Training  in  the  Treatment  of  Infantile  Paralysis,  Boston, 
1916. 


ACUTE  ANTERIOR  POLIOMYELITIS  633 

flexion  at  tlie  hip  must  be  overcome  in  order  to  enable  the  patient 
to  stand  erect  without  bending  the  spine  forward  in  compensatory 
lordosis. 

Acquired  deformity  of  the  foot  is  far  less  resistant  than  is  the 
congenital  form,  and  by  tenotomy  and  the  proper  application  of 
manual  force  it  may  be  readily  straightened,  usually  at  one  sitting. 


Fig.  491. — The  secoiulaiy  changes  in  the  bones  after  complete  paralysis  of  long 
duration.  Extreme  atrophy,  subluxation  at  the  knee,  change  in  the  upper  surface 
of  the  tibia  and  distortion  of  the  epiphysis  of  the  femur. 

The  flexion  contraction  at  the  knee  may  be  overcome  also  by 
careful  and  persistent  manual  stretching  combined,  if  necessary, 
with  division  of  the  contracted  tissues  on  the  posterior  aspect  of 
the  joint.     (See  Reverse  Leverage.) 

The  flexion  deformity  at  the  hip  is  usually  fixed  by  the  contraction 
of  the  tissues  about  the  anterosuperior  spine  of  the  ilium,  includ- 
ing the  tensor  vaginae  femoris  muscle,  which  is  rarely  paralyzed. 
These  tissues,  together  with  the  fascia,  may  be  divided  subcutane- 
ously,  or  by  open  incision  if  necessary,  after  which  the  deformity 


634  DISEASES  OF   THE  NERVOUS  SYSTEM 

may  be  reduced  by  gradual  forcible  extension  of  the  thigh  while  the 
pelvis  is  fixed  by  flexing  the  other  limb  upon  the  body.  In  cases 
of  extreme  contraction  Soutter's  operation  is  most  effective.^  An 
incision  is  made  just  behind  the  anterosuperior  spine,  extending 
directly  downward  about  three  inches.  The  fascia  is  then  incised 
transversely  from  the  anterosuperior  spine  to  the  trochanter. 
With  an  osteotome  contracted  muscles  and  fascia  attached  to  or 
about  the  anterior  and  inferior  spines  are  separated  from  the  under- 
lying bone  inside  and  outside  the  iliac  crest  and  its  anterior  margin, 
including  in  some  instances  the  spines  themselves  so  that  the 
attachments  of  the  contracted  tissues  are  actually  displaced  down- 
ward when  the  limb  is  h^yperextended.  When  the  contractions 
are  overcome  lateral  deviation  at  the  knee  is  corrected,  if  it 
be  present,  either  by  force  or  by  osteotomy,  and  the  bony  points 
having  been  carefully  protected  by  padding  a  long  spica  plaster 
bandage  is  applied  to  fix  the  limb  in  hyperextension  at  the  hip. 

It  is  of  interest  to  note  in  this  connection  that  fat  embolism  is  a 
complication  to  be  considered  in  operations  on  atrophied  bones 
which  contain  an  abnormal  proportion  of  fat.  In  1000  operations 
of  this  class  collected  by  Renier^  there  were  10  cases  of  fat  embolism 
with  4  deaths.  The  use  of  the  Esmarch  bandage  during  the  opera- 
tion followed  by  complete  fixation  of  the  part  should  prevent  this 
complication. 

The  lesser  degrees  of  deformity  may  be  reduced  by  non-operative 
means,  for  example,  by  repeated  applications  of  plaster  bandages 
under  slight  corrective  force,  or  by  manipulation,  or  by  braces 
and  bandaging. 

Paralytic  knock-knee  may  be  corrected  by  the  Thomas  knock- 
knee  brace,  and  this  brace  when  attached  to  a  pelvic  band  is  a  useful 
form  of  support  in  the  routine  treatment  of  paralysis  of  the  leg 
(Fig.  462). 

The  Thomas  caliper  knee  brace  is  another  cheap  and  useful  sup- 
port. It  is  of  special  service  when  there  is  flexion  or  lateral  deform- 
ity of  the  limb  (Fig.  339). 

When  distortion  has  been  overcome  and  wdien  functional  use  has 
been  made  possible  by  proper  support,  the  development  of  active 
muscles  which  had  been  disused  because  of  the  distortions,  and  of 
those  in  which  part  of  the  muscular  substance  has  been  retained,  is 
surprising.  In  many  of  these  cases  the  distortions  which  develop 
during  the  temporary  paralysis  have  alone  prevented  recovery,  and 
this  latent  power  may  be  revived  even  after  years  of  disuse.  Thus 
in  many  instances  prognosis  is  impossible  until  the  deformities  have 
been  corrected  and  until  the  limb,  properly  supported,  has  been 
enabled  to  resume  its  function.  Aside  from  the  correction  of 
deformity,  operative  treatment  is  undertaken  when  the  area  of 

1  Boston  Med.  and  Surg.  Jour.,  March  12,  1914. 
-  Mlinchen.  med.  "Wchnschr.,  November,  1907. 


ACUTE  ANTERIOR  POLIOMYELITIS 


635 


final  paralysis  can  be  definitely  determined,  for  the  purpose  of 
rebalancing  the  residual  power,  and  assuring  stability. 

It  is  of  most  service  for  the  deformities  of  the  feet  and  it  is 
described  more  at  length  in  the  chapter  on  Talipes. 

Of  these  operations,  the  most  effective  is  astragalectomy  and 
backward  displacement  of  the  foot,  since  by  this  means  the  centre 
of  uncontrolled  movement  is  removed  and  the  malleoli  are  implanted 
on  the  basic  structure  of  the  foot  near  its  bearing  centre.  It  is  the 
most  dependable  of  all  operations  because  the  structural  conditions 
are  changed  in  adaptation  to  the  disability.     (See  Talipes.) 


FiCr.  492. — Paralysis  of  the  left  deltoid  muscle,  showing  the  elevation  of  the  shoulder 
when  the  patient  attempts  to  abduct  the  arm.     (See  Fig.  483.) 


Muscle  and  Tendon  Transplantation. — The  object  of  this 
operation  is  to  utilize  the  residual  muscular  power  to  best  advan- 
tage, transferring,  if  possible,  an  agent  of  deformity  to  a  point 
where  it  may  be  functionally  useful.     (See  Talipes.) 

Transplantation  of  the  Trapezius  for  Paralysis  of  the 
Deltoid  Muscle. — In  cases  of  this  class  there  is  disabling  laxity 
or  even  subluxation  at  the  articulation,  and  the  exaggerated  eleva- 
tion of  the  shoulder  when  the  patient  attempts  to  raise  the  arm 
makes  the  disability  very  noticeable  (Fig.  492). 


636 


DISEASES  OF  THE  NERVOUS  SYSTEM 


A  broad  flap  of  skin,  its  convexity  over  the  upper  quarter  of  the 
deltoid  muscle,  is  raised,  exposing  the  trapezius.  This  is  thoroughly 
separated  from  its  attachment  to  the  acromion  and  sufficiently  from 
the  spine  of  the  scapula  and  clavicle.  The  arm  is  then  abducted  and 
the  flap  of  muscle,  made  tense,  is  sewed  with  numerous  sutures  to 
the  atrophied  deltoid  and  underlying  capsule  of  the  joint,  or  a  flap  of 
fascia  from  the  thigh  may  be  quilted  to  the  trapezius  and  attached 
to  the  bone  and  periosteum  at  the  insertion  of  the  deltoid.     The 


Fig.  493. — Illustrating  the  improvement  in  the  range  of  abduction  obtained  by  trans- 
plantation of  the  trapezius  muscle.     The  line  of  the  incision  is  shown. 


skin  wound  is  then  closed  and  the  limb  is  fixed  in  complete  abduc- 
tion by  means  of  a  plaster  bandage.  This  attitude  should  be 
retained  for  several  months.  Afterward  massage  and  exercises 
should  be  employed.  The  humerus  is  usually  held  securely,  a  certain 
power  of  abduction  is  restored,  and  the  functional  ability  often 
greatly  increased  (Figs.  492  and  493). 

If  the  capsule  is  greatly  relaxed  the  redundancy  may  be  removed 
before  transplanting  the  trapezius.     The  upper  portion  of  the  pec- 


ACUTE  ANTERIOR  POLIOMYELITIS 


637 


toralis  major  muscle  may  be  transplanted  in  place  of  the  trapezius. 
A  part  of  the  sternal  and  half  of  the  clavicular  attachments  of  the 
muscle  are  separated  as  far  as  possible  without  injuring  the  nerve 
supply,  turned  over  the  shoulder  and  attached  to  the  spine  of  the 
scapula.  Spitzy  has  divided  the  humerus  above  the  insertion  of  the 
pectoralis  major  and  rotated  it  outward  so  that  the  tension  on  its 
upper  fibres  enables  it  to  serve  as  an  abductor. 

Paralysis  of  the  muscles  of  the  arm  and  hand  is  comparatively 
unusual.  The  operation  of  tendon  shortening  or  implantation 
combined  with  transplantation  of  the  tendons  of  one  or  more  active 
muscles  may  be  of  service  in  the  treatment  of  wrist-drop,  and 
opportunities  may  suggest  themselves  in  other  situations  when- 
ever it  is  possible  to  utilize  the  muscular  power  to  better  advantage. 


Fig.  494. — Showing  restoration  of  the  power  of  extension  by  transplantation  of  the 

biceps  muscle. 


Transplantation  of  the  Hamstring  Muscles. — One  of  the 
most  satisfactory  operations  is  transplantation  of  the  biceps  for 
paralysis  of  the  quadriceps  extensor  muscle.  An  incision  is  made 
over  the  muscle  from  the  middle  of  the  thigh  to  the  head  of  the 
fibula.  The  tendon  of  insertion  together  with  a  part  of  its  cartilag- 
inous attachment  is  separated  and  is  dissected  back  with  the  short 
attachment  of  the  biceps  to  the  femur  to  a  point  where  the  muscle 
may  pull  in  a  direct  line  from  the  tuberosity  to  the  patella.  An 
incision  is  then  made  over  the  patella  exposing  the  tendon  of  the 
quadriceps.  This  is  split  together  with  the  underlying  capsule  of 
the  joint.     A  second,  lateral  opening  is  made  in  the  outer  wall  of  the 


638  DISEASES  OF   THE  NERVOUS  SYSTEM 

capsule  and  the  biceps  tendon  is  draTm  through  a  capacious  tunnel 
between  the  deep  fascia  and  the  skin  through  the  lateral  opening, 
out  tlu'ough  the  quadriceps  tendon  and  is  firmly  secured  to  the 
periosteal  covering  of  the  patella  which  is  separated  sufficiently 
from  the  bone  to  permit  it.  It  is  also  sutured  to  the  quadriceps 
tendon  and  to  the  openmg  in  the  capsule,  so  that  there  is  no  possi- 
bility of  slipping.  The  wounds  are  closed  and  the  limb  is  supported 
in  the  extended  position  for  several  months. 

If  the  biceps  is  weak,  the  semimembranosus  and  tendonosus  may 
be  transplanted  in  the  same  manner,  the  openings  being  made  on  the 
inner  side  of  the  capsule.  The  result  is  not  as  satisfactory  as  a 
rule  because  the  muscular  puU  is  less  direct.  In  some  instances  all 
the  hamstrings  may  be  transplanted,  but  unless  the  calf  muscle  is 
active  there  is  danger  of  recurvation  at  the  knee.  If  the  calf  muscle 
retains  its  power,  or  if  the  resistance  to  dorsal  flexion  is  restored  by 
astragalectomy  and  backward  displacement  of  the  foot,  the  gain  in 
power  is  usually  sufficient  to  enable  the  patient  to  discard  apparatus.^ 

The  sartorius  and  tensor  vaginse  muscles  have  been  transplanted 
for  the  same  piupose,  but  the  results  are  not  satisfactory  because 
the  biceps  is  made  tense  when  the  limb  is  thrown  forward,  while 
these  muscles  are  relaxed  by  the  same  movement. 

Silk  Ligajmexts. — ^The  use  of  silk  for  the  purpose  of  elongating 
tendons  of  active  muscles  in  order  to  transplant  them  to  a  point  of 
election  was  popularized  by  Lange,  who  demonstrated  that  silk 
tendons  were  in  some  instances  eventually  transformed  by  penetra- 
tion and  absorption  mto  fibrous  cords. 

Silk  ligaments  are  used,  as  the  name  implies,  as  direct  internal 
stays  to  hold  a  part  in  normal  position.  It  is  assumed  by  those  who 
employ  them  that  they  are  later  changed  to  actual  ligaments  and 
thus  to  permanent  supports.  This,  however,  is  very  doubtful. 
They  are  of  service  as  internal  splmts,  as  adjuncts  to  apparatus,  to 
tendon  transplantation,  or  arthrodesis,  or  even,  it  may  be,  during  the 
stage  of  recovery  as  a  protection  to  weakened  muscles,  but  as  per- 
manent and  independent  supports  they  are  usually  disappointing. 

Silk  ligaments  are  chiefly  employed  in  the  treatment  of  paral}i;ic 
talipes,  but  Bartow  advocates  their  use  for  insecurity  at  the  larger 
joints.- 

A  tj^ical  operation  is  that  for  laxity  at  the  shoulder-joint  follow- 
ing paralysis  of  the  supportmg  muscles.  A  short  incision  is  made 
over  the  acromion  and  a  drill  with  an  eye  at  the  point  is  pushed 
thi'ough  the  acromion  and  the  head  of  the  hmnerus  emerging  through 
an  incision  in  the  skin  near  the  base  of  the  greater  tuberosity.  A 
looped  cord  of  silk  is  attached  to  the  drill  which  is  withdra^Mi. 
A  second  similar  incision  is  made  with  the  drill  through  the  acromion 

^  The  functional  results  in  a  large  number  of  these  cases  have  been  analyzed  by 
Klinberg,  Am.  Jour.  Orthop.  Surg.,  Julj-,  1917. 
2  Am.  .Jour.  Orthop.  Surg.,  May,  1913. 


ACUTE  ANTERIOR  POLIOMYELITIS  639 

and  humerus  emerging  about  three-fourths  of  an  inch  from  the  first. 
The  lower  end  of  the  silk  cord  is  then  passed  beneath  the  muscle, 
attached  to  the  drill  and  drawn  upward  through  the  opening  in  the 
acromion.  The  two  ends  are  then  tied  to  one  another,  holding  the 
humerus  firmly  in  the  socket.  The  arm  is  afterward  supported  for 
four  or  more  weeks. 

Bartow  uses  strands  of  14  to  16  Corticelli  silk,  doubled  or  quad- 
rupled, according  to  the  strength  required,  paraffined  according  to 
the  Lange  method. 

Arthrodesis. — Arthrodesis  is  most  often  employed  at  the  ankle- 
joint,  to  fix  the  foot  at  a  right  angle  with  the  leg.  (See  Talipes.) 
In  exceptional  cases  arthrodesis  or  excision  at  the  knee  may  be 
advisable  in  the  older  patients,  but  in  young  subjects  the  strain 
upon  the  long,  weak  lever  formed  by  the  two  bones  will  almost 
always  induce  deformity.  Arthrodesis  at  the  hip  may  be  of  service 
in  cases  of  complete  paralysis  of  the  pelvic  muscles.  The  opera- 
tion is  performed  as  for  arthrotomy  in  the  treatment  of  con- 
genital displacement  of  the  hip  (see  page  555),  except  that  the  car- 
tilage is  thoroughly  removed  from  the  head  of  the  femur  and  from 
the  acetabulum.  A  short  spica  plaster  support  should  be  worn 
until  union  is  firm. 

Arthrodesis  at  the  shoulder  may  be  of  service  when  the  supporting 
muscles  are  paralyzed.  The  method  of  opening  the  joint  is  described 
on  page  497. 

Arthrodesis  at  the  elbow  and  wrist  may  assure  an  improved 
attitude.  Whenever  possible  the  operation  should  be  reinforced 
by  tendon  or  muscle  transplantation.  Anchylosis  or  even  satis- 
factory fixation  cannot  be  attained  by  this  means  until  the  bones 
are  sufficiently  developed.  The  operation  should  not  be  performed 
therefore  until  the  child  is  at  least  eight  years  of  age. 

Osteotomy. — In  some  instances,  particularly  in  the  extreme 
deformities  in  the  adult,  osteotomy  of  the  femur  at  the  hip  or  knee 
may  be  necessary  in  order  to  overcome  resistant  distortion. 

Nerve  Grafting. — A  number  of  operations  have  been  performed 
with  the  aim  of  restoring  muscular  power  in  paralyzed  muscles  by 
uniting  the  inactive  nerve  with  one  which  is  still  in  communication 
with  the  nerve  centres.  Some  encouraging  results  have  been 
reported,  but  the  operation  is  still  in  the  experimental  stage.  It 
must  be  assumed  on  the  one  hand  that  the  inactive  and  degenerated 
nerve  is  capable  of  regeneration  and  on  the  other  that  the  one  to 
which  it  is  attached  is  capable  of  taking  on  a  double  function.^ 

Review  of  Treatment. — ^This  consists  in  absolute  rest  during  the 
acute  or  sensitive  stage,  together  with  a  suitable  brace  to  hold 
the  part  in  the  best  possible  position  for  usefulness  when  the  final 
extent  of  the  paralysis  has  become  evident.     During  the  stage  of 

1  Steindler:  Am.  Orth.  Assn.,  December,  1916. 


640  DISEASES  OF   THE  NERVOUS  SYSTEM 

recovery  any  treatment  that  will  improve  the  nutrition  of  the  part  is 
of  service;  methodical  movements  of  the  joints  and  muscle  training 
being  of  special  value.  The  limb  in  which  the  circulation  is  deficient 
should  be  protected  from  the  cold  by  proper  covering,  and  its  nutri- 
tion may  be  improved  by  the  direct  application  of  heat,  the  hot-air 
or  hot-water  bath  both  being  useful.  Eventually  functional  use, 
which  is  made  possible  even  in  extreme  cases  by  apparatus,  is  of  the 
first  importance  in  preserving  and  stimulating  whatever  muscular 
power  remains,  and  special  gymnastic  exercises  to  this  end  may  be 
employed  if  practicable.  The  prevention  of  deformity  during  the 
growing  period  is  of  the  first  importance.  Every  morning  and  night 
the  joints  of  the  paralyzed  part  should  be  passively  moved  through 
normal  range  in  all  directions  in  order  to  prevent  the  gradual  limita- 
tion of  the  range  of  motion  which  is  the  first  indication  of  deform- 
ity. Lateral  deviation  of  the  limb  or  foot  may  be  prevented  by 
passive  manipulation  and  by  careful  adjustment  or  modification  of 
the  support.  Braces  should  be  strong  and  as  simple  as  may  be  in 
construction.  Elastic  bands  and  springs,  applied  with  the  design  of 
replacing  paralyzed  muscles,  are  of  little  practical  use,  since  they 
are  ineffective  in  action,  difficult  to  adjust,  and  easily  disarranged. 
The  parent,  when  treatment  is  begun,  must  be  impressed  with  the 
fact  that  a  brace  must  be  strong  enough  to  serve  its  purpose;  that 
its  period  of  usefulness  is  limited,  and  that  it  must  be  replaced  when 
it  is  outgrown;  that  the  breaking  of  a  brace  from  time  to  time  is 
unavoidable,  and  that  such  accidents,  insofar  as  they  are  evidences 
of  the  functional  activity  of  the  patient,  are  favorable  indications. 

When  the  area  of  persistent  paralysis  can  be  definitely  determined, 
operative  treatment  with  the  aim  of  relieving  the  patient  from 
■  braces  or  for  the  purpose  of  making  them  less  burdensome  is  often 
of  great  value. 

Careful  supervision  of  the  patient,  even  though  the  weakness  is 
not  great,  will  be  necessary  during  the  period  of  growth.  The  con- 
trast between  the  development  and  symmetry,  the  muscular  power 
and  practical  utility  of  a  limb  that  has  received  this  care  and  super- 
vision, and  one  that  has  been  neglected,  is  sufficiently  striking 
to  impress  anyone  with  the  necessity  for  this  tedious  and  apparently 
never-ending  treatment. 

Thus,  in  this  as  in  other  chronic  diseases  and  disabilities  the 
character  and  the  duration  of  the  treatment,  its  object,  and  the 
final  results  that  one  may  expect  to  attain  by  it,  should  be  explained 
to  the  parents  when  the  care  of  the  patient  is  undertaken. 


CHAPTER    XVIII. 

DISEASES  OF  THE  NERVOUS  SYSTEM  (Continued). 

CEREBRAL  PARALYSIS  OF  CHILDHOOD— SPASTIC 
PARALYSIS. 

Cei&bral  paralysis  or  palsy  is  in  orthopedic  practice  second  only 
in  frequency  and  importance  to  anterior  poliomyelitis.     It  is,  how- 
ever, entirely  different  in  its  distribution  and  in  its  effects.     It  is  a 
form  of  disability  that  is  characterized  by  motor  weakness,  by  stiff- 
ness and  loss  of  control,  rather  than  by  paralysis.     It  affects  entire 
members  and  it  results  in  atrophy,  contractions,  and  deformity. 
It  may  involve  half  the  body — hemiplegia. 
It  may  be  limited  to  the  lower  extremities — paraplegia. 
It  may  involve  both  the  upper  and  lower  extremities — diplegia. 
In  rare  instances  but  one  extremity  is  affected — monoplegia. 

Distribution. — In  451  cases  of  cerebral  paralysis  analyzed  by 
Peterson,^  332  were  of  the  hemiplegic  type,  73  were  of  the  diplegic 
type,  and  46  were  of  the  paraplegic  type.  Of  121  consecutive  cases 
observed  at  the  Hospital  for  Ruptured  and  Crippled,  63  were 
paraplegic  or  diplegic  and  58  were  hemiplegic. 

Of  132  cases  of  hemiplegia  analyzed  by  Thomas  but  36  were  of 
congenital  origin,  a  large  proportion  of  the  remainder  followed 
acute  infectious  disease,  the  paralysis  resulting  from  hemorrhage, 
thrombosis,  embolism,  or  encephalitis.^ 

Etiology  and  Pathology. — Cerebral  paralysis  may  be  divided  into 
two  classes — the  congenital  and  the  acquired.  The  diplegic  and 
paraplegic  forms  are  usually  congenital,  the  hemiplegic  form  is  more 
often  acquired. 

Congenital  Paralysis. — Paralysis  of  intra-uterine  origin  may  be  the 
result  of  maldevelopment  or  injury  or  a  secondary  effect  of  inter- 
current disease  of  the  mother.  Paralysis  caused  by  injury  at  birth 
is  usually  supracortical  the  result  of  rupture  of  bloodvessels  of  the 
meninges  due  to  prolonged  labor  or  to  the  pressure  of  instruments. 

Acquired  Paralysis. — Acquired  paralysis  may  be  due  to  hemor- 
rhage, embolism,  thrombosis,  or  to  disease.     Sachs^  presents  the 
following  classification  of  causes  and  effects: 
Paralysis  of  Intra-uterine  Origin. 

Large  cerebral  defects — true  porencephaly. 

Hemorrhages  of  intra-uterine  Origin — softening. 

Agenesis  corticalis. 

1  American  Text-book  of  Diseases  of  Children. 

2  Bull.  Jahns  Hopkins  Hosp.,  June,  1909. 

3  Sachs:  Nervous  Diseases  of  Children. 
41 


642  DISEASES  OF   THE  NERVOUS  SYSTEM 

Paralysis  Acquired  after  Birth. 

1.  Meningeal  hemorrhage — ^very  seldom  intracerebral.  Embol- 
ism: thrombosis  in  marantic  conditions,  and  occasionally  from 
syphilitic  endo-arteritis.  Results  of  these  vascular  lesions:  cysts; 
softening;  atrophy;  sclerosis,  diffuse  and  lobar. 

2.  Chronic  meningitis. 
Paralysis  Occurring  during  Labor. 

Meningeal  hemorrhage — very  seldom  intracerebral.  Resulting 
conditions:  meningo-encephalitis  chronica;  sclerosis;  cysts;  atro- 
phies; porencephalies. 

3.  Hydrocephalus. 

4.  Primary  encephalitis  (Striimpell). 

General  Symptoms. — Motor. — The  effect  of  the  lesion  of  the 
brain  and  of  the  secondary  changes  in  the  anterior  pyramidal  tracts 
of  the  cord  is  to  impair  the  voluntary  control  of  the  limbs  supplied 
from  the  affected  area,  and  at  the  same  time  the  inhibition  of  the 
higher  centres  is  impaired  or  lost.  Thus,  together  with  the  loss  of 
power,  there  is  a  corresponding  exaggeration  of  the  reflexes  causing 
a  spastic  rigidity  of  the  limbs  varying  with  the  degree  of  voluntary 
control.  This  induces  distortion,  which  finally  becomes  fixed  by 
the  adaptive  changes  in  the  tissues.  As  the  centres  for  the  nutrition 
of  the  paralyzed  parts  are  not  involved,  the  muscles  do  not  waste 
and  the  circulation  is  but  little  affected.  Thus  the  atrophy  as  com- 
pared with  paralysis  of  spinal  origin  (anterior  poliomyelitis)  is 
comparatively  slight,  and  this,  together  with  the  retardation  of 
growth,  is  due  rather  to  the  general  effects  of  the  disease  and  to  the 
loss  of  function  than  to  the  direct  influence  of  the  nervous  lesion. 

Mental. — In  this  form  of  paralysis  the  lesion  is  of  the  brain,  and 
the  direct  injury  of  its  structure  and  the  interference  with  its 
development  is  likely  to  cause  mental  impairment.  This  mental 
impairment  is  usually  more  marked  in  the  paraplegic  or  diplegic 
than  in  the  hemiplegic  form,  because  in  the  latter  but  half  the  brain 
is  involved,  and  because  the  injury  or  disease  occurs  at  a  later  period 
of  its  development.  So,  also,  the  mental  development  is  usually 
less  interfered  with  in  the  paraplegic  than  in  the  diplegic  type. 
For,  although  both  hemispheres  were  involved,  yet  the  recovery  of 
power  in  the  arms  shows  that  the  injury  was  less  extensive  than 
when  the  weakness  persists  in  one  or  both  of  the  upper  extrem- 
ities. 

It  is  estimated  that  in  50  per  cent,  of  the  hemiplegic  cases  the 
patients  are  feeble-minded,  although  comparatively  few  (13  per 
cent.)  are  idiotic.  In  the  paraplegic  and  diplegic  forms  of  paralysis 
about  70  per  cent,  of  the  patients  are  feeble-minded,  and  from  40 
to  50  per  cent,  are  idiotic.     (Sachs.) 

Epilepsy  is  an  accompaniment  of  about  45  per  cent,  of  all  forms 
of  cerebral  paralysis,  and  in  20  per  cent,  of  the  cases  athetoid  or 
associated  movements  in  the  paralyzed  parts  persist.     (Peterson.) 


CEREBRAL  PARALYSIS  OF  CHILDHOOD 


643 


Congenital  Weakness  and  Paralysis. — The  congenital  form  of 
cerebral  paralysis  is  often  seen  in  orthopedic  clinics,  because  the 
effect  of  the  lesion  of  the  brain  in  retarding  physical  development 
first  attracts  the  attention  of  the  mother.  Thus  infants  are  brought 
for  examination  because  they  are  unable  to  sit  or  stand  at  the  usual 
time.  In  certain  instances  the  cause  of  the  physical  weakness  is 
simple  idiocy.  In  such  cases  the  vacant  expression,  the  inability 
of  the  child  to  recognize  even  its  mother,  the  extreme  weakness,  and 
the  absence  of  the  spastic  rigidity  of  the  limbs  will  make  the 
diagnosis  clear. 


Fig.  495. — Congenital  cerebral  diplegia  (idiocy). 


In  another  class  of  cases  the  weakness  appears  to  be  caused  simply 
by  retarded  cerebral  development.  The  patient  is  apathetic  and 
weak,  but  there  is  no  evidence  of  paralysis,  and  the  comparative 
intelligence  of  the  patient  distinguishes  this  type  from  the  idiotic 
class. 

In  the  characteristic  form  of  cerebral  paralysis  as  seen  in  early 
life  the  child  may  be  idiotic,  or  simply  apathetic,  or  fairly  normal 
in  intelligence,  but  it  is  always  weak,  and  in  the  sitting  posture  the 
spine  is  usually  bent  backward  into  a  long,  more  or  less  rigid  curve. 


644  DISEASES  OF   THE  XERYOUS  SYSTEM 

It  makes  no  effort  to  stand,  and  when  placed  in  the  erect  posture  it 
will  be  noticed  that  the  thighs  are  usually  pressed  closely  against 
one  another  and  that  the  feet  are  extended.  The  limbs  are  "stiff"." 
There  is  a  peculiar  resistance  to  flexion  at  the  extended  joints,  which 
slowly  gives  way  under  steady  pressure.  This  is  the  characteristic 
spastic  rigidity  (Fig.  495). 


Fig.  496. — Spastic  paraplegia. 

Deformities. — These  children  usually  begm  to  stand  and  to  walk 
at  about  the  third  year  or  later  with  an  awkward,  shuffling  gait; 
the  limbs  are  usually  flexed,  adducted,  and  rotated  mward;  the 
knees  touch  one  another  or  the  legs  may  be  crossed,  while  the  feet 
turn  inward  in  a  persistent  attitude  of  slight  equinovarus.  The 
equilibriiun  is  very  easily  distm'bed,  partly  because  of  the  deformities 
and  partly  because  of  direct  lesion  of  the  brain.  In  the  majority 
of  the  congenital  cases  the  paralysis  is  paraplegic  in  its  distribution; 
perhaps  15  per  cent,  are  of  the  hemiplegic  variety,  and  in  a  somewhat 
larger  number  the  paralysis  is  diplegic  in  distribution  (Fig.  495). 

The  t^'pical  deformity  of  the  foot  is  equinovarus,  but  in  older 


CEREBRAL  PARALYSIS  OF  CHILDHOOD 


645 


subjects  who  have  walked  about  m  the  attitude  of  flexion  at  the  hips 
and  knees  there  may  be  an  accommodative  distortion  of  the  foot 
toward  valgus,  or  even  to  an  extreme  degree  of  calcaneovalgus. 

Mentality. — As  has  been  stated,  in  a  certain  number  of  cases  the 
intelligence  is  not  impaired,  but  more  often  the  patients  are  distinctly 
feeble-minded.  They  are  very  nervous,  easily  startled,  emotional, 
and  are  often  unable  to  speak  distinctly,  yet  it  is  interesting  to 
note  that  this  peculiar  emotional  ex- 
citability often  passes  for  brightness 
of  intellect  and  quickness  of  percep- 
tion. In  fact,  parents  often  remain 
unconvinced  that  the  child  is  lacking 
in  mental  power  until  it  reaches  an 
age  when  comparison  with  other  chil- 
dren makes  this  conclusion  inevitable. 

Acquired  Paralysis. — As  in  adult  life, 
the  common  form  of  acquired  cerebral 
paralysis  in  childhood  is  hemiplegia. 
About  two-thirds  of  all  the  cases  occur 
in  the  first  three  years  of  life;  and  in 
about  20  per  cent,  of  these  the  affection 
of  the  brain  is  a  complication  of  infec- 
tious disease.  The  onset  is  usually  sudden, 
and  is  accompanied  in  the  majority  of 
cases  by  fever,  convulsions,  and  loss  of 
consciousness.  When  the  child  regains 
consciousness  the  paralysis  of  the  arm 
and  leg  is  at  once  evident,  and  in  about 
20  per  cent,  of  the  cases  the  face  is  par- 
alyzed also. 

Deformities. — At  first  the  paralysis  is 
a  simple  powerlessness,  but  soon  the 
exaggeration  of  the  reflexes  is  evident. 
As  has  been  stated,  there  is  a  loss  of 
voluntary  power  and  an  increase  of  the 
reflexes  or  "stiffness"  of  the  paralyzed 
members.  They  are  no  longer  competent 
to  assume  the  more  difficult  attitudes 
and  functions,  and  these  are  replaced  by 
those  that  are  simpler;  thus  flexion  be- 
comes habitual. 

In  typical  hemiplegia  the  foot  is  plantar  flexed  and  adducted.  The 
leg  is  flexed  on  the  thigh  and  the  thigh  on  the  trunk,  and  with  the 
flexion,  adduction  is  usually  combined.  The  arm  is  held  against 
the  thorax,  the  forearm  is  flexed  upon  the  arm  in  an  attitude  mid- 
way between  pronation  and  supination.  The  hand  is  flexed  upon 
the  arm  and  inclined  toward  the  ulnar  side  and  the  fingers  are  clasped 
over  the  adducted  thumb  (Fig.  497). 


Fig. 


497. — Acquired 
hemiplegia. 


cerebral 


646  DISEASES  OF   THE  NERVOUS  SYSTEM 

Disability, — Tlie  loss  of  power  is  not  absolute;  in  most  instances 
the  patient  is  able  to  walk  with  a  noticeable  limp,  dragging  the 
stiffened  and  distorted  limb,  which  serves  as  a  prop  rather  than  as 
an  active  support.  So,  also,  the  control  of  the  upper  extremities  is 
in  part  retained;  the  patient  is  able  to  abduct  the  arm,  to  partly 
extend  the  forearm,  sometimes  to  extend  the  fingers  and  to  abduct 
the  thumb,  but  the  power  to  dorsiflex  the  hand  and  at  the  same 
time  to  extend  the  fingers  is  not  usually  retained  in  a  case  of  this 
character. 

Loss  of  Growth. — ^The  growth  of  the  patient  as  a  whole  is  usually 
retarded  to  a  certain  extent  by  the  lesion  of  the  brain.  There  is  also 
an  inequality  in  the  growth  of  the  two  halves  of  the  body.  This 
inequality  is  more  marked  in  the  upper  than  in  the  lower  extremity. 
Shortening  to  the  extent  of  an  inch  in  the  lower  extremity  is  not 
usually  exceeded,  but  the  growth  of  the  arm  and  hand  may  be  very 
decidedly  retarded.  This  disproportionate  loss  of  growth  in  the 
upper  over  the  lower  extremity  depends  primarily  upon  the  inter- 
ference with  function.  The  lower  extremity  is  rarely  disabled  to 
an  extent  that  prevents  its  use  in  locomotion,  consequently  its 
nutrition  is  preserved;  whereas  the  same  degree  of  paralysis  of  the 
arm  utterly  unfits  it  for  its  more  complex  functions.  With  the 
disuse  there  is  a  corresponding  diminution  of  nutrition  and  a  con- 
sequent atrophy  and  loss  of  growth. 

Extreme  deformity  and  disability,  as  in  the  type  described,  are 
rather  unusual.  In  many  instances  there  is  almost  complete  recovery 
from  the  paralysis,  only  an  awkwardness  and  slowness  of  movement, 
combined  with  an  increase  of  reflexes  and  a  slight  hemiatrophy  of 
the  body  exists.  In  some  cases  a  slight  degree  of  equinus  is  the  only 
deformity;  in  others  weakness  of  the  arm  may  persist,  although 
complete  control  of  the  lower  extremity  has  been  regained. 

The  final  effect  of  the  paralysis  is  almost  always  more  marked  in 
the  upper  than  in  the  lower  extremity;  thus,  when  contractions 
and  deformities  of  the  lower  extremity  are  present  the  arm  and  hand 
are  often  practically  disabled. 

Treatment. — 1.  Hemiplegia. — ^The  treatment  from  the  orthopedic 
stand-point  consists  in  stimulating  the  nutrition  of  the  paralyzed 
parts,  in  preventing  deformity,  and  in  improving  the  functional 
ability.  The  results  of  treatment  are,  of  course,  very  greatly 
influenced  by  the  mental  condition  of  the  patient.  If  the  mental 
power  is  not  impaired  one  may  count  upon  the  efforts  of  the  patient 
for  aid;  whereas,  if  the  patient  is  idiotic  there  is  but  little  encourage- 
ment for  active  treatment.  If  the  patient  is  seen  before  the  sec- 
ondary contractions  have  appeared,  deformity  may  be  prevented 
in  great  degree  by  regular  massage  and  by  passive  movements  in 
the  directions  opposed  to  the  habitual  positions.  If  the  spastic 
contraction  is  slight  a  light  jointed  leg  brace  attached  to  a  pelvic 
band  may  be  used.     By  this  means  the  movements  are  controlled 


CJBREBBAL  PARALYSIS  OF  CHILDHOOD  ()47 

and  the  excessive  expenditure  of  nervous  energy  necessary  to  guide 
the  hmb  may  be  lessened.  If  the  support  is  supplemented  by  mas- 
sage and  regular  exercises  the  control  of  the  limb  may  be  greatly 
improved. 

In  many  instances  the  patients  are  not  seen  until  late  childhood, 
when  the  deformities  have  become  fixed.  The  foot  is  usually 
turned  inward  and  downward  (equinovarus) ;  there  is  flexion  at 
the  knee  and  often  flexion  and  adduction  at  the  hip,  the  resistance  of 
the  contractions  being  dependent  upon  the  duration  of  the  deform- 
ity. Jn  such  cases  the  distortions  must  be  corrected  by  force  and 
by  division  of  more  resistant  tissues,  including  often  the  tendo- 
Achillis,  the  plantar  fascia,  and  in  many  instances  the  hamstrings 
and  the  adductors  of  the  hip.  The  limb  is  then  fixed  in  a  plaster- 
of-Paris  bandage  for  a  sufficient  time  to  overcome  the  more  direct 
tendency  to  deformity.  In  correcting  hemiplegic  or  paraplegic 
deformity  one  should  be  particular  to  overcome  resistant  contraction 
at  the  knee  before  dividing  the  tendo-Achillis,  for  if  the  patient  is 
permitted  to  walk  afterward  with  a  flexed  knee  calcaneus  deformity 
may  be  induced.  Division  of  the  hamstring  tendons  through  an 
open  incision  is  therefore  indicated  in  all  resistant  cases  of  this 
class.  As  additional  precaution  the  foot  at  the  time  of  an  operation 
should  be  fixed  at  a  right  angle  with  the  limb;  not  overcorrected 
as  is  usual.  When  the  bandage  is  removed  a  brace  is  of  service  in 
guiding  the  limb,  and  regular  massage  and  forcible  passive  move- 
ments together  with  proper  exercises  should  be  employed  whenever 
practicable.  In  this  class  of  cases  the  deformities  may  be  overcome 
in  most  instances,  but  there  is  a  tendency  toward  flexion  at  the  knee, 
and  stiffness  and  awkwardness  in  movement  usually  persist. 

Muscle  Transplantation. — Muscle  transplantation  is  often  of 
service  in  lessening  the  tendency  to  deformity  and  restoring  balance. 

At  the  knee  the  transplantation  of  the  biceps  to  the  front  of  the 
limb  is  indicated  in  cases  of  persistent  flexion.  At  the  foot  the 
transplantation  of  the  tibialis  anticus  to  the  outer  border,  and  if 
necessary,  the  tibialis  posticus  to  the  peroneus  brevis  will  prevent 
recurrence  of  varus.     The  operations  are  described  elsewhere. 

In  many  of  the  milder  hemiplegic  cases  the  only  deformity  is  of 
the  foot.  This  should  be  treated  by  division  of  the  tendo-Achillis 
and  by  support  for  a  time  until  the  deformity  habit  has  disappeared. 

If  the  arm  is  but  slightly  affected  persistent  exercise  will  greatly 
improve  its  ability.  In  the  more  extreme  cases,  in  which  the  fingers 
are  clasped  over  one  another,  treatment  is  of  little  avail.  In  another 
class,  in  which  the  patient  has  the  power  of  extending  the  fingers 
only  when  the  wrist  is  flexed,  the  power  of  dorsiflexion  may  be 
restored  or  improved  by  transplanting  the  flexors  of  the  carpus  on 
the  radial  and  ulnar  border  to  the  extensors,  which  have  been  over- 
lapped and  shortened  to  the  proper  extent.  These  tendons  may  be 
exposed  by  lateral  incisions,  and  may  be  attached  to  the  dorsal 


648 


DISEASES  OF   THE  NERVOUS  SYSTEM 


tendons  by  passing  them  abont  the  border  of  the  radins  and  of  the 
nhia,  or  directly  throngh  an  opening  in  the  interosseous  hgament. 
The  transplantation  of  other  tendons  may  be  of  service,  bnt  the 
operation  is  limited  in  usefulness  for  the  reasons  stated.  Athetoid 
movements  of  the  hand  and  arm  may  be  relieved  somewhat  by  pro- 
longed fixation  in  a  plaster  bandage  by  arthrodesis  at  the  wrist- 
ioint  or  bv  division  of  the  motor  nerves. 


Fig.  498. — Cerebral  paraplegia,  second  stage  in  treatment,  the  long  replaced  by 
the  short  spica.  This  patient,  at  the  age  of  eight  years,  was  unable  to  stand  without 
assistance.  The  spastic  contractions  and  deformities  were  overcome  by  tenotomies 
and  bj^  force,  and  a  double  long  spica  bandage  was  applied.  Tliis  was  worn  for  eight 
months.  It  was  then  replaced  by  the  support  shown  in  the  illustration.  Six  months 
later  this  was  removed.  There  is  at  present  no  deformity,  and  the  child  walks  fairly 
well. 


2.  Paraplegia. — The  treatment  of  spastic  paraplegia  is  more 
difficult  than  that  of  hemiplegia,  because  the  disability  is  very 
much  greater  and  because  the  mental  impairment  is  usually  more 
marked. 

In  general,  the  treatment  in  infancy  is  by  massage  and  by  manipu- 
lation.    When  the  child  shows  a  desire  to  walk  an  attempt  should 


CEREBRAL  PARALYSIS  OF  CHILDHOOD  649 

be  made  to  relieve  the  spastic  contractions.  In  certain  instances 
complete  correction  of  all  deformities,  followed  by  prolonged  fixation 
of  each  joint  in  the  overcorrected  attitude,  may  be  of  service  (Fig. 
488) .  This  may  be  combined  with  multiple  tenotomies  if  the  con- 
tractions are  more  resistant.  The  advantage  of  tenotomy^  aside 
from  the  simple  correction  of  deformity,  is  that  by  elongation  of 
the  tendon  the  response  to  the  exaggerated  motor  impulses  is 
lessened  and  an  opportunity  for  more  effective  control  is  afforded. 
The  beneficial  effect  of  complete  division  of  contracted  parts  in 
checking  spasmodic  contractions  is  very  marked  in  older  patients. 
The  indications  for  muscle  transplantation  are  the  same  as  in 
hemiplegia. 

Except  in  the  very  mild  cases  of  paraplegia,  and  as  a  temporary 
support  to  retain  the  limbs  in  the  improved  position  after  operative 
treatment,  braces-  are  of  little  value.  The  trunk  is  not,  as  a  rule, 
deformed  except  in  the  diplegic  cases  in  which  the  mental  impair- 
ment is  great.  Manipulation,  massage,  and  educational  gymnastics 
are  of  service  in  correcting  and  preventing  this  distortion. 

Foerster's  Operation. — Foerster's  operation  is  laminectomy 
and  division  of  the  posterior  nerve  roots,  dorsal  to  their  ganglia. 

The  purpose  of  the  operation  is  to  check  the  impulses  from  the 
periphery  that  excite  muscular  activity,  and  thus  to  assure  better 
control. 

In  spastic  paraplegia  the  nerves  involved  are  the  four  lower  lum- 
bar and  two  upper  sacral,  and  according  to  Foerster's  latest  teach- 
ing, all  the  roots  are  divided,  except  that  of  the  supply  of  the  anterior 
thigh  group  from  the  first  or  third  lumbar  nerves  as  determined  by 
direct  electrical  tests. 

In  the  upper  extremity  the  nerves  involved  are  the  four  lower 
cervical  and  first  dorsal. 

It  is  hardly  necessary  to  describe  the  steps  of  the  operation,  or  its 
modifications,  since  it  has  been  practically  abandoned  in  the  class 
of  cases  of  orthopedic  interest.^ 

Operations  on  Motor  Nerves. — These  operations  have  been 
conducted  for  the  purpose  of  weakening  the  power  of  the  spastic 
muscles  and  thereby  lessening  the  disparity  between  the  over- 
active and  the  inactive  groups. 

One  method  is  to  induce  temporary  paralysis  by  injecting  alcohol 
about  the  nerve  trunk  supplying  the  spastic  muscles,  in  order  that 
the  weaker  groups  may  be  trained  to  better  advantage. 

Another,  is  to  induce  permanent  paralysis  in  parts  of  the  muscle 
to  reduce  its  power  to  the  desired  degree.  This  is  Stoffel's 
operation.^ 

Stoffel  has  called  attention  to  the  fact  that  a  nerve  trunk  is  com- 
posed of  numerous  distinct  fibres  establishing  a  direct  communi- 

1  T.  Gumbel:  Ber.  klin.  Wchnschr.,  li,  29. 

2  Milnchen.  med.  Wchnschr.,  1911,  No.  47;  Am.  Jour.  Orthop.  Surg.,  May,  1913. 


650  DISEASES  OF   THE  XERVOUS  SYSTEM 

cation  from  the  Derve  cells  to  the  mdividual  muscular  bundles 
making  up  the  muscle. 

The  power  of  the  overactive  muscles  can  be  reduced  by  dividing 
certain  of  the  branches  of  distribution  to  the  muscle  itself,  or  by 
cutting  these  m  the  main  trunk  after  identification  by  electrical 
tests.  The  degree  of  weakening  must  be  tentative  and  determmed 
therefore  by  the  experience  of  the  operator. 

Stoffel's  operation  may  be  of  service  in  the  treatment  of  spastic 
contraction  of  the  upper  extremity,  particularly  of  the  athetoid 
t^'pe,  because  even  slight  improvement  in  control  may  be  of  value. 

In  the  lower  extremity,  however,  the  conditions  are  different. 
Spastic  muscles  are  not  actually  stronger  than  normal  muscles, 
nor  is  the  chief  disability  of  the  inactive  muscles  local  weakness  but 
rather  loss  of  control  due  to  the  impanment  of  the  cortical  centres. 

The  relative  functional  strength  of  the  calf  muscle,  by  far  the 
strongest  of  those  involved,  may  be  lessened  to  any  degree  by 
operative  elongation  of  its  tendon,  or  even  by  fixation  of  the  foot 
m  dorsal  flexion  for  a  sufficient  time. 

Unfortunately  temporary  complete  paralysis  or  mechanical  weak- 
ening of  the  stronger  group  is  not  necessarily  followed  by  sufficient 
gain  in  the  weaker  muscles  to  assm'e  function.  Temporary  paralysis 
by  means  of  alcohol  injections  as  an  aid  in  correcting  deformity  and 
m  muscle  training  is  to  be  preferred  to  operations  designed  to  induce 
permanent  partial  paralysis,  except  perhaps,  to  relieve  pronation 
m  the  upper,  or  for  adduction  deformity  in  the  lower  extremity,  but 
both  have  a  very  limited  application  in  orthopedic  practice  as  com- 
pared to  dnect  operation  on  the  muscles. 

Decompression  of  the  Brain. — In  a  large  proportion  of  the  cases  the 
disability  is  caused  by  injm-y  at  birth  and  subdm'al  hemorrhage. 
In  some  instances  the  effused  blood  has  been  removed  immediately 
by  openmg  the  dm^a  with  complete  relief  of  s^Tnptoms. 

William  Sharpe^  is  an  advocate  of  decompression  in  later  child- 
hood when  intracranial  pressure  can  be  estabhshed  by  the  ophthal- 
moscope and  by  lumbar  punctm'e.  He  has  operated  on  236  cases. 
Eighty  diplegic,  117  hemiplegic,  and  3S  paraplegic,  with  a  mor- 
tality of  S  per  cent.     In  all  but  13  cases  improvement  was  noted. 

Prognosis. — ^It  is  stated  by  Peterson-  that  the  patients  in  whom 
the  paralysis  is  paraplegic  or  diplegic  in  distribution  usually  die 
before  the  twentieth  year,  and  that  but  few  of  those  m  whom  it  is 
hemiplegic  reach  the  age  of  forty.  This  prognosis  applies,  it  may 
be  assumed,  rather  to  the  extreme  cases  accompanied  by  mental 
impairment  than  to  the  milder  forms.  In  almost  all  cases  the 
patient,  even  if  idiotic,  is  finally  able  to  stand  and  to  walk.  As  a 
rule  there  is  for  a  time  a  gradual  improvement  in  motor  power  and 
in  mental  control  as  well.     It  is  evident  that  m  a  class  in  which 

1  Surg.,  Gj-nec.  and  Obst.,  Januarj-,  1917. 
=  Tr.  Am.  Orthop.  Assn.,  1900,  xiii. 


PROGRESSIVE  MUSCULAR  ATROPHY  651 

mental  enfeeblement  is  so  common  and  in  which  epilepsy  is  present 
in  so  large  a  proportion  of  cases,  moral  and  mental  training  is  of 
great  importance. 

Orthopedic  treatment,  although  it  has  no  direct  action  upon  the 
lesion  in  the  brain,  certainly  has  an  indirect  effect  upon  the  mental 
as  well  as  upon  the  physical  condition  of  the  patient. 

When  deformity  has  been  corrected  and  when  contractions  have 
been  overcome,  functional  use  requires  less  mental  effort;  and  motor 
control  may  be  still  further  improved  by  drilling  the  patient  con- 
stantly^ in  simple  movements.  Such  exercises  improve  the  motor 
communications  and  the  ability  of  the  paralyzed  part  as  well. 

According  to  von  Baeyer'^  an  inelastic  band  about  3  cm.  wide 
buckled  about  the  thigh,  not  tight  enough  to  affect  the  circulation, 
reinforces  the  inhibiting  power  and  lessens  the  spastic  contractions. 

SPASTIC  SPINAL  PARALYSIS. 

Occasionally  cases  of  spastic  paraplegia  are  seen  in  which  there  is 
no  cerebral  impairment.  In  such  cases  the  lesion  appears  to  be 
confined  to  the  spinal  cord  and  to  be  a  degeneration  of  the  distal 
portions  of  the  pyramidal  tracts  due  to  imperfect  development.^ 
The  treatment  is  similar  to  the  ordinary  form  of  spastic  paraplegia, 
but  the  prognosis  is  far  more  encouraging. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Progressive  muscular  atrophy,  as  the  term  implies,  is  a  progressive 
wasting  of  the  muscles,  with  corresponding  loss  of  power,  termi- 
nating finally  in  paralysis  and  deformity.  Its  cause  is  apparently 
developmental  defect. 

Under  this  title  are  included  two  varieties  of  disease: 

1 .  The  myelopathic  form,  in  which  the  primary  disease  is  appar- 
ently of  the  spinal  cord. 

2.  The  myopathic  form,  in  which  the  disease  appears  to  be  pri- 
marily of  the  nerve  terminals  and  the  muscular  fibres. 

The  second  variety  is  usually  designated  as  muscular  dystrophy 
to  distinguish  it  from  the  spinal  form. 

Myelopathic  Paralysis  or  Atrophy. — The  myelopathic  form  of 
muscular  atrophy,  the  Aran-Duchenne  type,  usually  begins  in  the 
small  muscles  of  the  hands  and  spreads  from  the  periphery  to  the 
trunk.  Fibrillary  twitching  of  the  affected  and  unaffected  muscles 
is  fairly  constant,  and  the  reaction  of  degeneration  may  be  present. 
The  disease  is  practically  limited  to  adults,  and  from  the  orthopedic 
stand-point  it  is  of  little  interest.  In  another  form,  the  Charcot- 
Marie-Tooth  type,  usually  classed  with  the  muscular  atrophies, 
the  paralysis  may  begin  in  the  muscles  of  the  legs,  causing  deformity 

1  Von  Baeyer:  Miinchen.  med.  Wchnschr.,  Ixii,  No.  4. 

2  Spiller:  Phila.  Med.  Jour.,  June  21,  1902. 


652 


DISEASES  OF   THE  NERVOUS  SYSTEM 


of  the  equinus  or  equinovarus  variety.  The  lesion  of  the  cord  is  of 
the  anterior  corniia,  and  resembles  closelv'  that  of  the  subacute  form 
of  anterior  poliomyelitis. 


Fig.  499.  —  Progressive  muscular 
dystrophy,  showing  the  enlargement  of 
the  calves  and  the  atrophy  of  the 
shoulder  muscles. 


Fig.  500. — Progressive  muscular  dj^s- 
trophy,  facioscapulohumeral  type.  Ex- 
treme lordosis  and  flexion  contractions 
at  the  laips. 


Myopathic  Paralysis  or  Muscular  Dystrophy. — The  myopathic 
form  of  muscular  atrophy  may  be  preceded  by  apparent  hyper- 
trophy (pseudohypertrophic  muscular  paralysis),  it  may  be  pri- 
marily atrophic,  or  the  two  forms  may  be  combined. 

It  differs  from  the  myelopathic  form  in  several  particulars.  It  is 
a  disease  of  childhood.  It  is  often  hereditary  and  its  distribution 
is  different. 


PROGRESSIVE  MUSCULAR  ATROPHY  653 

The  affection  is  divided  according  to  the  distribution  into  two 
main  varieties: 

1.  The  facio-scapulo-humeral  type  (Landouzy-Dejerine),  in  which 
the  muscles  of  the  face  and  shoulder-girdle  are  primarily  affected 
(Fig.  500). 

2.  The  juvenile  form  of  Erb,  in  which  the  muscles  of  the  back  and 
of  the  upper  arms  are  first  involved. 

The  etiology,  pathology,  and  clinical  course  of  the  atrophic  do 
not  differ  essentially  from  the  pseudohypertrophic  form. 

PseiKiohypertrophic  Muscular  Paralysis. — Pseudohypertrophic 
paralysis  is  characterized  by  progressive  weakness  of  the  muscles 
of  the  trunk  and  of  the  legs,  associated  with  apparent  hypertrophy 
of  the  calves  due  in  great  part  to  a  deposit  of  fat  in  the  wasting 
muscles  (Fig.  489). 

The  sjanptoms  are  caused  by  a  degenerative  atrophy  of  the  nerve 
terminals  and  of  the  muscular  fibres  and  an  increase  of  the  connec- 
tive tissue  and  replacement  of  the  muscular  substance  by  fat. 

Diagnosis. — ^The  interest  in  this  latter  affection  from  the  ortho- 
pedic stand-point  lies  in  the  diagnosis  in  the  early  stage  of  the  affec- 
tion. At  this  time  the  patient  is  evidently  weak;  he  walks  with  an 
awkward,  shambling  gait,  and  climbing  stairs  is  especially  difficult. 
There  is  usually  an  increased  lordosis  and  a  peculiar  swaying  or 
waddle,  a  disinclination  to  stoop,  and  an  evident  difficulty  in  regain- 
ing the  erect  posture,  and  there  may  be  discomfort  or  pain  referred 
to  the  lumbar  region.  If  the  disease  is  advanced,  the  peculiar  hard, 
resistant  enlargement  of  the  calves,  combined,  it  may  be,  with 
atrophy  of  the  muscular  groups  of  the  upper  extremity,  and  weak- 
ness of  the  muscles  of  the  back,  makes  the  diagnosis  evident,  but  in 
young  children  the  disease  may  be  mistaken  for  Pott's  disease,  simjjle 
weakness,  or  postural  deformity.  Although  there  is  a  superficial 
resemblance  to  the  general  symptoms  of  Pott's  disease,  yet  the' 
specific  signs  of  disease  of  the  vertebrae,  pain,  and  muscular  spasm 
are  absent. 

Weakness,  a  result  of  malnutrition  or  disease,  is  general  in  char- 
acter and  its  cause  is  usually  apparent;  it  is,  of  course,  not  accom- 
panied by  local  hypertrophy.  Retarded  cerebral  development 
causes  general  weakness  as  far  as  inability  to  stand  is  concerned, 
but  the  cause  is  in  this  class  also  usually  apparent. 

Postural  deformities  in  childhood  always  have  a  cause,  and  as 
one  is  not  content  to  treat  a  deformity  without  ascertaining  its 
cause,  this  search  will  bring  to  light  the  peculiar  symptoms  of  the 
disease. 

Treatment. — In  certain  instances  the  discomfort  referred  to  the 
back,  due  in  part  to  the  lordosis,  may  be  relieved  by  a  light  spinal 
support.  Massage  and  muscle-training  will  enable  the  patient  to 
utilize  the  remaining  power  to  best  advantage. 

In  the  later  stages  of  the  disease  there  may  be  secondary  deformi- 


654  DISEASES  OF   THE  NERVOUS  SYSTEM 

ties,  most  marked  in  the  feet,  which  may  be  fixed  in  the  equinus  or 
equniovarus  attitude.  This  deformity  may  be  corrected  by 
tenotomy  or  otherwise,  if  the  disabihty  is  not  progressing  rapidly. 

HEREDITARY  ATAXIA.     FRIEDREICH'S  DISEASE. 

Hereditary  ataxia  is  an  ataxic  paraplegia  caused  by  sclerosis  of 
the  posterior  and  lateral  colimms  of  the  spinal  cord.  The  early 
s^Tiiptoms  are  incoordmation  and  weakness  of  the  legs;  later  simi- 
lar symptoms  appear  in  the  upper  extremities,  and  speech  is  affected. 
In  well-marked  cases  there  is  usually  distortion  of  the  feet  toward 
equinus  or  equinovarus,  and  occasionally  a  posterior  or  lateral 
curvature  of  the  spine. 

NEURITIS. 

Neuritis  sometimes  follows  contagious  disease,  rheumatism, 
alcoholism  and  the  like.  The  pain  is  of  an  aching,  throbbing  char- 
acter with  occasional  shooting  pain  along  the  nerve,  usually  accom- 
panied by  a  sensation  of  heaviness  and  weakness,  and  it  may  result 
in  temporary  paralysis  of  the  dorsal  flexors  of  the  foot,  cause  toe-drop, 
and,  finally,  deformity.  In  such  cases  the  foot  should  be  supported 
by  a  brace  or  plaster  support  in  normal  position.  This  not  only 
pre^'ents  deformity,  but  it  hastens  the  ciu-e  by  pre\'enting  tension 
upon  and  structural  lengthening  of  the  weakened  muscles.  The 
same  treatment  may  be  applied  for  wrist-drop  from  metallic  poison- 
ing. The  hand  should  be  supported  by  a  suitable  brace  in  the 
attitude  of  dorsiflexion  until  the  muscles  have  recovered  their  power. 
Obstetrical  paralysis  has  been  considered  under  aftections  of  the 
shoulder. 

HYSTERICAL  JOINT  AFFECTIONS  AND  DEFORMITIES.     FUNC- 
TIONAL AFFECTIONS  OF  THE  JOINTS. 

So-called  hysterical  and  functional  affections  may  be  divided 
into  two  groups: 

1.  Those  in  which  there  is  no  actual  disease  or  weakness. 

2.  Those  in  which  the  symptoms  of  disease  or  injury,  or  of  their 
effects,  are  exaggerated  or  persist  undul3\ 

The  first  class  of  cases  is  small,  the  second  is  large. 

Simulation,  whether  voluntary  or  involuntary,  of  organic  disease 
can  deceive  only  those  who  are  not  familair  with  the  characteristics 
of  the  disability  that  is  simulated.  Every  disease  has  certain  well- 
defined  s^^nptoms  which  can  no  more  be  imitated  by  a  well  person 
than  a  disabled  part  can  suddenly  take  on  the  normal  appearance 
and  function. 


THE  NEUROTIC  SPINE 


655 


THE  NEUROTIC  SPINE. 

The  "neurotic"  spine  is  much  more  common  m  adolescence  and 
in  adult  life  than  in  childhood,  and  the  subjects,  usually  females, 
are  often  of  a  nervous  or  neurasthenic  type.  In  certain  instances 
the  symptoms  appear  to  have  been  induced  by  injury,  and  in 
others  by  worry  or  overwork. 


Fig.  501. — The  neurotic  spine.     Characteristic  attitude. 

Symptoms. — ^The  patient  usually  complains  of  a  dull  pain  in 
the  back  of  the  neck,  or  in  the  lumbar  or  sacral  region,  of  a  constant 
tired  feeling,  and,  not  infrequently,  of  sharp  neuralgic  pain  localized 
about  a  certain  point  in  the  spine,  often  the  vertebra  prominens. 
The  contour  of  the  spine  may  be  normal,  but  most  often  there  is  a 
lessening  of  the  lumbar  lordosis,  a  backward  inclination  of  the  body 
and  a  forward  droop  of  the  head,  an  attitude  that  signifies  muscular 
weakness  and  strain  upon  the  ligaments.  One  of  the  common  symp- 
toms of  the  neurotic  spine  is  extreme  local  sensitiveness,  or  hyperes- 
thesia, of  the  skin  at  certain  points  along  the  spinous  processes. 


656 


DISEASES  OF   THE  NERVOUS  SYSTEM 


Thus,  if  one  passes  the  finger  gently  along  the  spine  the  patient  will 
often  shrink  or  cry  out  because  of  the  pain.  As  a  rule  there  is  no 
limitation  of  motion  or  muscular  spasm.  The  pain  is  local,  not 
referred  to  the  terminations  of  the  nerves;  in  fact,  the  symptoms 
are  in  great  part  subjective  and  irregular  in  character,  as  contrasted 
with  those  of  actual  disease,  which  are  objective  and  well-defined. 

Treatment. — The  treatment  of  the  neurotic  spine  must  be 
general  in  character,  as  indicated  by  the  condition  of  the  patient. 
Locally,  a  light  back  brace  or  a  long  corset,  reinforced  if  necessary 
by  light  steel  back  bars,  adds  greatly  to  the  comfort  of  the  patient. 
The  application  of  the  cautery  is  particularly  efficacious  in  relieving 
the  local  sensitiveness.  INIassage  and  light  exercises  may  be 
employed  in  the  later  treatment.  Weak  feet  are  often  associated 
with  this  condition.  In  such  instances  appropriate  treatment  often 
induces  a  marked  improvement  in  the  general  condition. 


Fig.  502. — Hysterical  scoliosis.     (Schuster.) 


THE  HYSTERICAL  SPINE. 

The  hysterical  spine  is  considered  usually  as  synonymous  with 
the  neurotic  spine,  but  as  there  are  many  individuals  who  suffer 
from  sensitive  spines  who  are  not  hysterical,  it  would  seem  proper 
to  limit  the  latter  term  to  the  hysterical  class. 

Symptoms. — The  local  symptoms  do  not  differ  particularly 
from  those  of  the  neurotic  spine  except  that  in  certain  instances 
actual  deformity  may  be  present.  This  is  usually  an  exaggerated 
lateral  distortion,  most  marked  in  the  lumbar  region.     Like  hvsteri- 


THE  HYSTERICAL  SPINE  657 

cal  distortions  elsewhere,  it  may  follow  injury,  and  it  may  be  claimed 
that  this  injury  was  the  direct  cause  of  the  deformity.  Except,  how- 
ever, as  a  possible  cause  of  the  appearance  of  a  particular  manifesta- 
tion of  the  mental  condition,  it  is  evident  that  no  form  of  injury 
could  explain  the  symptoms  or  the  deformity.         <* 

"Hysterical  Scoliosis." — A  case  was  at  one  time  under  the 
writer's  observation  in  which  distortion  of  the  trunk  persisted  for 
more  than  a  year,  and  until  a  suit  for  damages  was  finally  decided. 
In  this  case  there  was  a  most  exaggerated  lateral  twist  of  the  spine, 
so  that  the  shoulder  approached  the  pelvis.  The  deformity,  how- 
ever, was  not  fixed,  but  it  could  be  completely  reduced  when  the 
patient  was  in  the  recumbent  posture.  There  was  no  paralysis, 
no  persistent  spasm,  no  evidence  of  disease  or  injury.  The  deform- 
ity was  of  a  nature  that  could  not  be  explained  by  any  conceivable 
lesion,  and  other  signs  of  hysteria  were  present.  Spontaneous  cure 
then  followed  to  be  succeeded  several  years  later  by  hysterical 
''club-feet"  (Fig.  502). 

"Hysterical  Hip." — The  hysterical  hip  is  supposed  to  simulate 
actual  tuberculous  disease. 

Diagnosis. — The  symptoms  of  actual  disease  of  this  joint  are  pain, 
limp,  limitation  of  motion  due  to  reflex  muscular  spasm,  muscular 
atrophy,  distortion,  and  later  the  local  signs  of  a  destructive  pro- 
cess; for  example,  heat,  swelling,  abscess,  displacement,  shortening 
of  the  limb,  and  the  like.  As  these  later  symptoms  could  not  be 
simulated,  they  need  not  be  considered. 

In  actual  disease  symptoms  and  effects  follow  one  another  in 
regular  sequence  and  correspond  closely  to  the  pathological  condi- 
tions that  cause  them.  Pain  is  not  a  pronounced  symptom;  it  is 
more  likely  to  be  concealed  than  exaggerated  and  it  is  usually 
referred  to  the  knee.  Local  sensitiveness  is  not  marked,  and  it  is 
often  absent.  Distortion  of  the  limb  if  present  before  the  destruc- 
tive changes  are  advanced  is  caused  by  involuntary  muscular  con- 
traction, and  whenever  this  distortion  is  great  the  reflex  muscular 
spasm,  which  involves  every  muscle  about  the  joint,  is  also  great; 
so  that  the  range  of  motion  is  restricted.  With  the  distortion  there 
is  always  a  corresponding  atrophy  of  the  muscles  of  the  limb.  If 
pain  is  present  it  is  usually  worse  at  night  than  during  the  day. 

The  simulation  of  hip  disease  is  characterized  by  an  exaggeration 
of  the  symptoms  and  by  absence  of  the  physical  signs  of  disease. 
There  is  usually  an  extreme  limp,  great  distortion,  marked  local 
sensitiveness  and  pain,  but  absence  of  muscular  spasm,  atrophy,  or 
other  signs  of  disease. 

The  age  of  the  patient,  the  history  of  the  supposed  disease,  and 
the  other  evidences  of  hysteria  that  are  usually  present  will  confirm 
the  diagnosis. 

The  same  principle  applies,  of  course,  to  the  differential  diagnosis 
of  simulated  disease  at  other  joints.     The  knee  and  the  hip-joint 
are  those  that  are  most  often  involved. 
42 


658  DISEASES  OF   THE  NERVOUS  SYSTEM 

"Hysterical  Talipes." — Local  deformity  distinct  from  simulated 
joint  disease  is  sometimes  seen.     The  differential  diagnosis  is  simple. 

Talipes  is  either  congenital  or  acquired.  Congenital  talipes 
and  all  the  acquired  varieties,  other  than  those  of  paralytic  origin, 
may  be  at  once  excluded  from  consideration.  Paralytic  talipes  in 
the  great  majority  of  cases  begins  in  early  childhood,  when  it  is 
either  caused  by  anterior  poliomyelitis  or  by  cerebral  hemiplegia  or 
paraplegia.  When  these  are  excluded  the  remaining  causes  of 
deformity  are  very  limited.  Each  variety  of  nervous  disease  has 
well-defined  s^^nptoms.  If  actual  paralysis  is  present  the  muscles 
atrophy  and  the  electrical  reactions  are  changed.  In  hysterical 
contractions  the  muscles  are  not  atrophied  except  to  the  degree 
explained  by  disuse  of  the  limb,  and  the  electrical  reactions  are 
unchanged. 

Treatment. — ^The  principles  of  the  treatment  of  pronounced 
hysteria,  of  which  simulated  joint  disease  and  deformity  are  but 
unusual  manifestations,  need  not  be  considered  at  length.  It  is 
evident,  of  course,  that  an  unequivocal  diagnosis  must  be  the  first 
and  essential  step  toward  cure.  In  this  class  of  cases  apparatus  is 
not  often  indicated  unless  the  deformity  has  persisted  for  so  long  a 
time  that  the  disused  muscles  have  become  incapable  of  performing 
their  proper  functions. 

"Neurotic  Joints." — In  this  class,  although  there  is  no  absolute 
distinction  between  it  and  the  preceding  variety,  there  is  usually  a 
physical  basis  for  the  symptoms,  however  much  they  may  be 
exaggerated. 

The  patients  are  not  usually  hysterical;  in  fact,  hysteria  in  the 
ordinarily  accepted  sense  is  uncommon,  and  although  the  larger 
proportion  of  patients  are  women,  yet  men  and  children  are  by  no 
means  exempt  from  the  so-called  functional  aft'ections. 

It  must  be  borne  in  mind,  also,  that  many  of  these  cases  are 
classed  as  neurotic  simply  because  the  cause  of  the  sjinptoms  is 
not  apparent.  It  may  be  inferred  that  as  diagnosis  becomes  more 
accurate  the  more  restricted  will  become  the  class  of  cases  of  purely 
imaginary  disability,  insofar  at  least  as  the  locomotive  apparatus 
is  concerned. 

Etiology. — A  "neurotic  joint"  is  often  caused  by  injury.  A 
sprain  of  the  ankle,  for  example,  may  have  been  treated  by  pro- 
longed fixation,  either  because  the  patient  had  originally  impressed 
the  physician  with  the  severity  of  the  s^inptoms  or  because  of  per- 
sistent discomfort.  When  the  dressing  is  removed  there  may  be 
congestion  due  to  impaired  circulation,  weakness  and  atrophy  of 
the  muscles  due  simply  to  disuse,  and  a  certain  degree  of  infiltration 
and  stiftness  caused  by  the  original  injury.  In  cases  of  this  char- 
acter the  disability  may  be  prolonged  because  the  patient  or  the 
physician  mistakes  the  effects  of  disuse  for  the  symptoms  of  serious 
injury  or  disease.     The  treatment  therefore  should  be  directed  to 


THE  HYSTERICAL  SPINE  659 

increasing  the  activity  of  the  circulation  and  thus  the  nutrition  of 
the  part,  by  counter-irritation,  by  massage,  by  passive  movements, 
by  voluntary  exercises  and  the  like,  but  cure  can  only  be  completed 
by  functional  use.  If  the  disability  is  of  long  standing  a  brace  may 
be  required  for  a  time  to  protect  the  part  from  injury,  and  to 
increase  the  patient's  confidence.  In  milder  cases  it  is  possible  that 
without  support  or  treatment,  other  than  an  assurance  of  the  absence 
of  serious  weakness,  cure  may  be  accomplished,  but  this  is  certainly 
unusual. 

Symptoms. — ^The  knee-joint  is  very  often  the  seat  of  so-called 
neurosis.  Injury  in  nervous  children  is  sometimes  followed  by  a 
persistent  flexion  contraction  that  may  continue  for  weeks  after  all 
local  signs  have  disappeared.  When  the  attempt  is  made  to 
straighten  the  knee  the  patient  screams  with  pain  and  the  mus- 
cular resistance  is  very  great.  In  such  cases  the  immediate  recti- 
fication of  deformity  under  anesthesia  and  the  application  of  a 
plaster  bandage  to  hold  the  limb  in  the  corrected  position  is 
indicated.  It  must  be  borne  in  mind  that  the  persistent  assumption 
of  a  deformed  position  for  weeks  or  months  must  induce  structural 
changes  in  the  contracted  muscles  and  weakness  in  the  opposing 
groups.  Thus  some  assistance  may  be  required  in  the  treatment 
even  of  the  purely  hysterical  deformities  because  of  this  weakness. 

In  all  forms  of  traumatic  neurosis,  so-called,  the  possibility  of  a 
physical  basis  for  the  symptoms  should  be  considered,  the  location 
of  the  pain  or  discomfort,  and  its  connection  with  certain  movements 
or  attitudes  should  be  investigated.  If  such  discomfort  is  induced 
by,  or  is  aggravated  by  a  certain  motion  or  attitude  it  is  reasonable 
to  infer  that  this  has  a  definite  cause.  In  such  cases  limitation  of 
the  movements  for  a  time  to  the  painless  range  of  motion  by  some 
form  of  support  may  be  indicated. 

Thus  far  injury  has  been  considered  as  the  starting-point  of  the 
symptoms,  but  in  many  cases  there  is  no  history  of  injury.  In  this 
class  the  symptoms  may  have  been  induced  by  some  form  of  arth- 
ritis, or  by  neuritis,  and  such  possible  causes  should  be  investigated 
and  excluded  before  the  diagnosis  of  simple  neurosis  is  made.  In 
neurasthenic  patients  or  those  who  are  anemic,  or  overworked,  the 
pain  and  discomfort  is  often  localized  in  the  spine,  the  "neurotic 
spine"  which  has  already  been  considered. 

Treatment. — In  the  treatment  of  all  cases  of  this  group,  the  general 
condition  of  the  patient  should  receive  consideration,  and  in  connec- 
tion with  the  local  treatment  a  change  of  occupation  and  of  scene 
is  often  of  advantage. 

It  is  hardly  necessary  to  insist  again  that  an  accurate  diagnosis  is 
the  first  essential  of  successful  treatment.  If  this  is  impossible  at 
least. one  may  by  the  exclusion  of  those  injuries  and  disabilities 
and  diseases  that  are  evidently  not  present  arrive  at  a  general  con- 
clusion as  to  the  character  of  the  ailment  and  shape  his  treatment 
accordingly. 


CHAPTER    XIX. 
CONGENITAL  AND  ACQUIRED  TORTICOLLIS. 

Synonym. — Wry-neck. 

Torticollis  is,  as  the  name  implies,  a  twisted  neck,  a  distortion 
caused  in  most  instances  by  active  contraction  or  by  shortening 
of  one  or  more  of  the  lateral  muscles  that  control  the  head. 

Similar  distortion  may 'be  due  to  disease  of  the  spine,  so-called 
false  torticollis,  but  this  should  be  classed  as  a  s^Tiiptom  of  the 
underlying  disease,  not  as  simple  torticollis,  of  which  the  distortion 
itself  is  the  important  disability  that  demands  treatment. 

Torticollis  may  be  divided  primarily  into  two  classes:  The  con- 
genital and  the  acquired. 

Congenital  torticollis  is  a  painless  shortening  of  the  tissues  on  one 
side  of  the  neck  of  intra-uterine  origin. 

Acquired  torticollis  is,  in  most  instances,  accompanied  in  its  early 
stages  by  local  pain  and  sensitiveness,  and  by  active  contraction  of 
the  affected  muscles.  After  a  time  these  acute  s;\TQptoms  dis- 
appear, leaving  simply  the  deformity.  Thus,  from  the  therapeutic 
stand-point,  torticollis  may  be  classified  as  acute  and  chronic,  the 
latter  class  including  the  congenital  form. 

The  sternomastoid  is  the  muscle  that  is  usually  involved  pri- 
marily, both  in  the  congenital  and  acquired  forms;  thus,  in  typical 
torticollis  the  head  is  drawn  somewhat  forward  and  is  inclined 
toward  the  contracted  muscle,  while  the  neck  is  pushed,  as  it  were, 
away  from  the  contraction  (Fig.  503) ;  the  chin  is  slightly  elevated, 
and  turned  toward  the  opposite  shoulder — an  attitude  explained  by 
the  normal  action  of  the  affected  muscle.  Irregular  distortions  of 
the  head,  as  posterior  or  anterior  torticollis  due  to  contraction  of 
muscles  other  than  the  sternomastoid,  are,  however,  not  infrequent. 
These  will  be  mentioned  in  the  consideration  of  the  forms  of  acquired 
torticollis. 

Statistics. — Torticollis  is  one  of  the  less  common  deformities. 
Se\'enty-five  new  cases  were  registered  at  the  Hospital  for  Ruptured 
and  Crippled  in  1915. 

Acquired  torticollis  is  by  far  the  more  frequent,  as  is  shown  by 
the  fact  that  of  507  cases  but  87  were  supposed  to  be  of  congenital 
origin. 

Of  the  87  congenital  cases  46  were  in  females.  The  contraction 
was  of  the  left  side  in  38  of  the  58  cases  in  which  the  affected  side  was 
specified.     Of  the  entire  number  of  cases  available  for  comparison 


CONGENITAL   TORTICOLLIS  661' 

246  were  in  females  and  198  in  males;  in  236  instances  the  contrac- 
tion was  on  the  left  and  in  196  on  the  right  side  of  the  neck.  From 
these  statistics  it  would  appear  that  the  deformity  is  somewhat  more 
common  in  females  than  in  males,  and  that  the  left  side  is  more 
often  affected  than  the  right. 

Congenital  Torticollis. — In  most  instances  the  deformity  of  con- 
genital torticollis  is  slight  at  birth,  and  it  may  not  attract  attention 
until  the  child  supports  the  head  or  even  walks.  Thus  it  is  often 
difficult  to  distinguish  the  congenital  form  from  the  deformity  that 
may  Have  been  acquired  in  infancy,  especially  as  the  patient  may  not 
be  brought  for  treatment  until  the  distortion  has  persisted  for  several 
years. 

In  early  infancy  slight  torticollis  may  be  demonstrated  by  fixing 
the  shoulder  on  the  affected  side  and  drawing  the  head  forcibly  in 
the  opposite  direction,  when  the  shortened  muscle  becomes  promi- 
nent beneath  the  skin,  evidently  restricting  the  range  of  motion. 
In  most  instances  the  sternal  division  of  the  muscle  appears  to  be 
more  shortened  than  the  clavicular  portion. 

In  exceptional  cases  the  deformity  even  in  infancy  may  be 
extreme,  and  it  may  be  accompanied  by  well-marked  asymmetry 
of  the  face  and  esven  by  distortion  of  the  skull.  In  this  class  the 
shortening  may  involve  all  the  lateral  tissues,  both  anterior  and 
posterior  and  is  often  complicated  by  malformation  of  the  cervical 
vertebrae.  If  asymmetry  is  present  at  birth  it  increases  somewhat 
with  growth.  Even  in  the  acquired  form  it  often  appears  soon  after 
the  onset  of  the  deformity,  becoming  more  marked  with  its  con- 
tinuance. Its  cause  is  the  constrained  attitude,  the  restriction  of 
normal  use,  and  consequently  of  the  blood  supply,  combined  with 
the  tension  upon  the  tissues  of  the  face,  as  is  evidenced  by  the  fact 
that  it  becomes  less  noticeable  after  the  deformity  has  been 
corrected. 

In  the  well-marked  cases  of  long  standing,  whether  congenital 
or  acquired,  the  face  on  the  affected  side  is  shorter  and  flatter,  the 
nose  and  the  corner  of  the  mouth  and  the  eyelids  even  are  drawn 
downward,  and  the  skull  shows  evidence  of  atrophy  and  deformity. 

Secondary  distortions  also  appear  in  the  trunk  in  chronic  cases. 
These  are  rotation  of  the  spine  to  compensate  for  the  lateral  distor- 
tion of  the  head  and  an  increase  in  the  dorsal  kyphosis,  "round 
shoulders."  Among  the  minor  secondary  deformities  upward 
bowing  of  the -clavicle  caused  by  the  tension  of  the  contracted 
muscle  may  be  mentioned  (Fig.  503). 

When  the  deformity  is  marked  or  of  long  standing  the  head  and 
neck  following  the  compensatory  convexity  of  the  cervical  spine 
are  displaced  toward  the  opposite  shoulder  (Fig.  504).  This  dis- 
placement relaxes  in  some  degree  the  contracted  tissues,  conse- 
quently the  lateral  distortion  of  the  head  is  lessened. 

The   compensatory  deformities  that   have   been   indicated   are 


662 


CONGENITAL  AND  ACQUIRED   TORTICOLLIS 


slight  in  infancy,  but  they  develop  in  later  childhood,  for  in  many 
instances  the  growth  of  the  afiected  muscle  is  checked;  thus,  an 
original  shortening  of  half  an  inch,  as  compared  to  its  fellow,  may 
be  increased  to  two  or  more  inches  in  later  years.  This  fact  empha- 
sizes the  importance  of  treatment  as  soon  as  may  be  possible  after 
the  distortion  is  discovered. 

As  has  been  stated,  the  important  contraction  is  usually  of  the 
sternomastoid  muscle,  but  if  the  deformity  is  uncorrected  all  the 
lateral  tissues  become  shortened. 


Fig.  503. — Left  torticollis,  apparently  of  congenital  origin,  showing  the  secondary 
distortions  of  head  and  face. 


Typical  wry-neck  caused  by  shortening  of  the  sternomastoid 
muscles  is  by  far  the  most  common  form  of  congenital  torticollis, 
but  occasionally .  cases  are  seen  in  which  the  head  is  but  slightly 
inclined  to  one  side  and  in  which  the  shortening  appears  to  involve 
the  lateral  tissues  in  general  rather  than  a  particular  muscle.  In 
rare  instances,  although  the  deformity  resembles  that  of  typical 
torticollis,  the  greatest  shortening  will  be  found  to  be  of  the  pos- 
terior muscles  on  one  side,  particularly  of  the  trapezius  and  the 
levator  anguli  scapulee.  Thus  the  scapula  may  be  elevated  and 
tilted  forward.  This  form  of  torticollis  may  be  combined  with 
congenital  elevation  of  the  scapula.  (See  page  200.)  Torticollis 
due  to  defective  development  of  the  upper  extremity  of  the  spine 
is  a  rare  deformity  that  does  not  require  special  description. 


CONGENITAL   TORTICOLLIS 


663 


Etiology. — It  may  be  assumed,  disregarding  the  possible  influence 
of  hereditary  predisposition,  that  congenital  torticolHs  is,  in  most 
instances,  caused  by  a  constrained  or  fixed  position  in  the  uterus  for 
a  longer  or  shorter  time  before  birth.  It  is,  in  fact,  a  simple  distor- 
tion, and  that  it  has,  in  the  majority  of  cases,  no  deeper  significance 
is  proved  by  the  fact  that  it  may  be  easily  and  completely  cured  by 
simple  division  or  elongation  of  the  contracted  tissues. 

Hematoma  of  the  Sternomastoid  Muscle  as  a  Possible  Cause  of  Tor- 
ticollis.— During  difficult  delivery,  fibres  of  the  muscle  are  ruptured, 
usua%  in  the  upper  or  middle  third  of  the  anterior  border,  hemor- 
rhage follows,  which  in  turn  is  surrounded  by  an  encapsulating  area 


Fig.  504. — Right  torticollis,    showing    the    displacement    of   the  head   toward   the 

opposite  side. 

of  inflammatory  material.  This  forms  a  firm,  cylindrical  tumor  in 
the  substance  of  the  muscle,  which  becomes  noticeable  about  two 
weeks  after  birth,  or  at  least  this  is  the  time  when  it  is  usually  dis- 
covered by  the  mother.  As  a  rule  the  tumor  is  not  sensitive  to 
pressure;  it  may  or  may  not  be  accompanied  by  restriction  of 
motion  in  the  direction  causing  tension  on  the  muscle.  The  tumor 
remains  for  from  three  to  six  months,  when  it  usuaUy  disappears, 
leaving  no  trace  of  its  presence. 

The  theory  of  Stromeyer  is  that  congenital  torticollis  is  usually 
caused  by  rupture  of  the  muscle  and  by  myositis  about  the  hema- 
toma that  may  involve  and  ultimately  destroy  a  large  part  of  the 


664  CONGENITAL  AND  ACQUIRED   TORTICOLLIS 

substance  of  the  muscle,  replacing  it  with  fibrous  tissue,  which, 
contracting,  causes  deformity. 
This  theory  is  extremely  improbable  for  the  following  reasons: 

1.  Ilupture  of  muscle  elsewhere  is  practically  never  followed  by 
myositis  and  contraction. 

2.  It  has  been  demonstrated  by  Heller^  that  it  is  impossible  to 
cause  myositis  and  contraction  by  any  form  of  injury  to  the  muscles 
of  animals  unless  it  be  combined  with  actual  infection  with  pyogenic 
germs. 

3.  Most  of  the  cases  of  congenital  torticollis  seen  soon  after  birth 
present  no  evidence  of  hematoma  or  injury,  viz. :  In  7  of  55  cases 
of  supposed  congenital  torticollis,  investigated  by  the  writer,  there 
was  a  history  of  injury  at  birth.  In  48  cases  no  mention  was  made 
of  injury.  In  the  7  cases  referred  to  the  deformity  was  accompanied 
by  hematoma  or  there  was  a  history  of  a  swelling,  apparently  of  this 
nature;  but  in  2  of  these  the  hematoma  was  coincident  with  intra- 
uterine shortening  of  the  muscle. 

4.  Cases  of  hematoma  of  the  sternomastoid  muscle  are  not,  as  a 
rule,  followed  by  torticollis.  Seven  consecutive  cases  of  hematoma 
were  examined  by  the  writer  with  special  reference  to  this  point. 
In  all  the  evidence  of  violence  in  delivery  was  clear.  Two  were 
delivered  by  forceps,  3  were  breech  presentations,  and  in  2  version 
was  performed.  In  1  case  an  arm  was  broken  and  in  another 
paralysis  resulted  from  injury  to  the  brachial  plexus.  Six  of  the 
children  lived  until  the  swelling  had  nearly  or  entirely  disappeared, 
and  in  none  did  torticollis  accompany  or  follow  hematoma. 

5.  In  certain  cases  a  congenitally  shortened  muscle  may  be  rup- 
tured at  delivery;  thus  the  hematoma  is  simply  a  complication  of 
torticollis,  not  its  cause.  Bruns^  has  reported  such  a  case,  and  2 
others  have  been  observed  by  the  writer,  in  1  of  which  club-foot 
was  present  also. 

6.  Hard  tumors  of  the  sternomastoid  muscle  are  not  always  the 
result  of  injury;  myositis  may  be  of  syphilitic  origin  apparently 
occurring  in  intra-uterine  life.  In  other  instances  tumors  of  fibrous 
or  sarcomatous  nature  have  been  removed  from  the  substance  of 
the  muscle.  Sixteen  cases  m  which  cartilaginous  nodules,  appar- 
ently of  congenital  origin,  were  found  in  the  muscle  have  been 
reported.^ 

One  may  conclude,  then,  that  congenital  torticollis  in  the  majority 
of  cases  is  of  intra-uterine  origin.  If  it  follows  mjury  at  birth  it  is 
probably  an  indirect  result  of  local  pain,  discomfort  and  irritation 
of  the  nerves  or  of  an  actual  infectious  inflammation  of  the  injured 
part  rather  than  an  effect  of  the  absorption  of  effused  blood. 


1  Heller:  Deutsch.  Ztschr.  f.  Chir.,  Band  xlix,  Heft  2  and  3,  234. 

2  Zent.  f.  Chir.,  1891,  No.  26. 

^  Leugemann:  Beitr.  z.  klin.  Chir.,  Band  xxx,  Heft  1. 


ACQUIRED   TORTICOLLIS  665 

Pathology. — In  the  ordinary  t^'pe  of  congenital  torticollis,  as 
demonstrated  at  operations  on  children,  the  substance  of  the 
affected  muscle  or  muscles  is  simply  lessened  in  amount,  and  there 
is  a  disproportionate  area  of  tendinous  substance  as  compared  to 
the  contractile  tissue.  In  other  instances  the  muscle  may  be 
almost  entirely  replaced  by  fibrous  tissue  or  it  may  be  traversed  by 
fibrous  bands,  or  patches  of  scar-like  tissue  may  be  distributed 
throughout  its  substance.  These  degenerative  changes,  considered 
to  be  evidences  of  preexisting  myositis,  are  more  common  among 
the  acquired  than  the  congenital  forms,  and,  as  a  rule,  they  are  found 
only  in  cases  of  long  standing.  Secondarily,  all  the  lateral  tissues 
of  the  neck  are  shortened  to  correspond  to  the  habitual  attitude, 
and  the  compensatory  curvatures  of  the  spine  in  time  become  fixed, 
so  that  torticollis  may  be  classed  as  one  of  the  causes  of  scoliosis. 

Acquired  Torticollis. — Acquired  torticollis  is  an  affection  of  early 
life,  at  least  80  per  cent,  of  the  cases  beginning  in  the  first  ten  years 
of  life. 

As  has  been  stated,  congenital  torticollis  is  usually  a  painless 
shortening  of  the  muscles,  while  acquired  torticollis  is,  as  a  rule,  a 
painful  affection  secondary  to  injury  or  disease  of  some  of  the 
structures  of  the  neck,  which  causes  irritation  of  the  peripheral 
nerves  and  active  contraction  of  the  neighboring  muscles.  Thus, 
as  a  rule,  the  number  of  muscles  involved  in  the  deformity  is  greater 
than  in  the  congenital  form;  for  example,  in  the  ordinary  form  of 
acquired  wry-neck  both  the  trapezius  and  the  sternomastoid  are  con- 
tracted; and  irregular  forms  of  distortion  caused  by  spasm  of  other 
muscular  groups  are  not  uncommon. 

Varieties. — The  varieties  of  acquired  torticollis  may  be  classified 
conveniently  as  follows : 

1.  The  simple  or  mechanical  form  due  to  scar  contraction  follow- 
ing destruction  of  the  skin  or  deeper  tissues,  as  from  burns  or 
disease. 

2.  Acute  torticollis  caused  by  direct  irritation  of  the  muscle,  by 
injury,  by  inflammatory  affections  of  the  surrounding  parts,  com- 
bined in  most  instances  with  irritation  of  the  peripheral  nerves, 
which  causes  reflex  contraction  of  certain  muscles  or  muscular  groups. 

3.  Spasmodic  Torticollis. — A  form  of  convulsive  spasm,  "  a  dis- 
order of  the  cortical  centres  for  rotation  of  the  head."     (Walton.) 

4.  Irregular  Forms  of  Torticollis. — Paralytic,  ocular,  psychical 
and  the  like. 

The  first  class,  that  due  to  scar  contraction,  needs  only  to  be 
mentioned. 

Etiology  of  Acute  Torticollis. — The  second  class  is  the  most 
important  form  of  torticollis,  both  as  to  frequency  and  as  to  its 
effect  in  causing  permanent  distortion.  Of  this  group,  one  of  the 
most  common  and  at  the  same  time  the  least  important  form  is  the 
simple  stiff'  neck,  supposed  to  be  due  to  cold  or  to  muscular  rheu- 


666  CONGENITAL  AND  ACQUIRED   TORTICOLLIS 

matism.  Its  onset  is,  in  childhood,  sometimes  accompanied  by 
sHght  fever  and  general  discomfort;  the  affected  muscle  is  somewhat 
sensitive  to  pressure  and  motion  or  tension  causes  discomfort.  The 
distortion,  in  great  part  voluntary  and  accommodative,  is  of  short 
duration  as  a  rule.  Strains  and  direct  injury  of  the  muscles  of  the 
neck  may  cause  deformity,  which  usually  disappears  when  the  local 
sensitiveness  has  subsided.  Traumatic  hematomata,  similar  to 
those  caused  by  injury  at  birth,  are  sometimes  observed  in  older 
subjects.  These  usually  disappear  after  a  time,  leaving  no  trace 
of  their  presence.  Another  form  of  torticollis  is  secondary  to  cellu- 
litis and  to  infiltration  following  the  breaking  down  of  tuberculous 
cervical  glands.  This  may  become  a  permanent  distortion  if  the 
deformity  is  allowed  to  persist  or  if  the  tissues  of  the  neck  are  in- 
jured by  the  suppurative  process. 

By  far  the  most  important  variety  of  this  class  is  the  acute  spastic 
torticollis  due  to  active  tonic  contraction  of  one  or  more  of  the 
muscles  of  the  neck.  The  exciting  cause  of  the  spasm  appears  to 
be  irritation  of  the  peripheral  nerves  in  the  nasopharynx  or  in  its 
neighborhood,  and  the  muscles  most  often  affected  are  those  sup- 
plied in  part  by  the  spinal  accessory  nerve.  Thus  torticollis  of 
this  form  may  follow  tonsillitis,  pharyngitis,  measles,  diphtheria 
and  the  like.  It  may  be  preceded  by  "toothache"  or  "earache," 
or  it  may  be  an  accompaniment  of  what  appears  to  be  the  ordinary 
form  of  stiff  neck  or  of  enlarged  or  suppurating  cervical  glands.  In 
this  form  the  torticollis  is  caused  directly  by  tonic  contraction  of 
the  muscles.  Reflex  spasm  of  this  character  is,  however,  often 
associated  with  distortion,  due  primarily  to  injury  of  the  neck  or  to 
some  local  inflammatory  process,  so  that  a  sharp  distinction  between 
the  divisions  of  this  second  class  is  impossible.  Many  of  the  patients 
are  known  to  be  of  a  nervous  temperament,  and  overstudy,  anxiety, 
sudden  shock,  and  the  like  are  considered  to  be  predisposing  causes. 

Enlarged  cervical  glands    .      .      14          "  Cold  in  the  neck"     ...  5 

Supporting  cer-\acal  glands       .      41          Rheumatism 18 

Scarlet  fever 14         Vaccinia 1 

Diphtheria    .            ....        7         Fever 6 

Mumps 6         Malaria 5 

Measles 2         Injury  of  the  neck        ...  35 

Sore  throat 8         Rhachitis 3 

Suppurative  otitis   •.      .      .      .       3         Syphilis 1 

Toothache 6         Cicatricial  contraction      .      .  3 

Cellulitis  of  the  neck     ...        2  

Furuncle  of  the  neck     ...        1                               Total    ....  181 

Torticollis  associated  with  chorea 4 

Torticollis  associated  with  epilepsy 1 

Torticollis  associated  with  cortical  irritation 5 

Torticollis  associated  with  hysteria 1 

Torticollis  associated  with  meningitis 1 

Torticollis  associated  mth  hemiplegia 3 

Spasmodic  torticollis 8 

"  Functional  torticollis " 8 

Total 31 


ACQUIRED   TORTICOLLIS 


667 


The  numerical  importance  of  this  variety  of  acquired  torticollis 
is  indicated  by  the  statistics  of  212  cases  treated  at  the  Hospital  for 
Ruptured  and  Crippled,  in  which  the  cause  seemed  to  be  apparent. 
Of  the  212  cases  181  may  be  fairly  assigned  to  this  class. 

The  apparent  exciting  causes  of  cases  of  acquired  torticollis 
treated  at  the  Hospital  for  Ruptured  and  Crippled  are  shown  in 
the  above  table. 

Symptoms  of  Acute  Torticollis. — As  a  rule  the  distortion  of  the 
neck,  slight  at  first,  is  mors  noticeable  at  night  than  in  the  morning; 
it  then  gradually  increases 
until  the  deformity  be- 
comes fixed.  In  other  in- 
stances the  onset  is  sud- 
den, sometimes  accom- 
panied by  fever. 

As  has  been  stated,  in 
most  instances  several 
muscles  are  more  or  less 
involved  in  the  contrac- 
tion, particularly  the 
sternomastoid  and  the 
trapezius,  and  in  such 
cases  the  deformity  is 
more  marked  and  persis- 
tent than  when  the  sterno- 
mastoid is  alone  affected. 
Less  often  the  contraction 
is  of  the  posterior  group, 
"  posterior  to  r  t  i  c  o  1 1  i  s" 
(Fig.  505),  the  head  being 
tilted  backward  and  the 
chin  turned  more  toward 
the  opposite  side  than  in 
the  typical  lateral  form. 
In  other  cases  the  con- 
traction appears  to  affect 
the  small  muscles  that 
control  the  joints  at  the 
upper  extremity  of  the 
spine,  when  the  head  may  be  tilted  forward  with  but  slight  lateral 
inclination,  resembling  closely,  except  in  the  history,  the  s^^nptomatic 
wry-neck  of  Pott's  disease.  In  rare  instances  the  muscles  on  both 
sides  of  the  neck  may  be  contracted  simultaneously  (Fig.  506). 
The  affected  muscles  are  usually  sensitive  to  manipulation  and 
attempted  rectification  of  the  deformity  causes  extreme  pain  and  is 
resisted  by  the  patient.  The  child  is,  as  a  rule,  nervous  and  irri- 
table; it  often  complains  of  neuralgic  pain  about  the  contracted 


Fig.  505. — Posterior  torticollis, 
week. 


Duration  one 


668 


COXGEXITAL  AND  ACQUIRED   TORTICOLLIS 


parts,  which  is  increased  by  sudden  or  unguarded  movements  or 
strain;  thus  "getting  the  patient  to  bed"  is  often  a  tedious  pro- 
ceeding, because  of  the  difficulty  of  supporting  the  head  comfort- 
ably with  the  piUows. 

In  many  instances  the  affection  is  of  short  duration;  in  others, 
particularly  those  in  wliich  the  reflex  spasm  is  aggravated  by  local 
inflammatory  processes,  there  appears  to  be  but  little  tendency 
toward  recovery.  In  such  cases,  after  several  weeks  or  months, 
the  local  pain  and  sensitiveness  may  subside,  together  with  the 
active  spasm,  but  the  deformity,  caused  by  adaptive  shortening  of 
the  muscles  and  fascia,  aggravated  in  some  instances  by  actual 
myositis,  persists.  The  muscles  atrophy  and  degenerate  and  pres- 
ent at  a  later  stage  the  same  pathological  appearances  that  are 
found  in  the  congenital  form. 


.v-  .-^    . 

-  ^-*s, 

i^ 

^^fc    '■^^B^p 

/M 

1 

A 

^gm 

i^  ^ 

Fig.  505. — Bilateral  contraction 
of  the  sternomastoid  and  trapezii 
muscles.     (See  Fig.  507.) 


Fig.  507. — Bilateral    torticollis    after    treat- 
ment.    (See  Fig.  506.) 


Diagnosis. — Torticollis  is  most  often  confounded  with  PotCs 
disease  and  in  its  acute  form  there  may  be  some  difficulty  in  distin- 
guishing between  the  two.  The  main  points  have  been  mentioned 
already  in  connection  with  Pott's  disease.  In  acute  torticollis  the 
affection  is  of  sudden  onset,  not  preceded  by  the  stiffness  and  neu- 
ralgic pain  that  characterize  tuberculous  disease.  The  deformity 
of  torticollis  is  almost  always  of  the  regular  tx]iQ — that  is,  the  head 
is  tilted  toward  the  contracted  muscles  while  the  chin  is  rotated 
in  the  opposite  direction.     The  spasm  and  contraction  of  the  affected 


DIAGNOSIS  669 

muscles  are  apparent^  and  direct  tension  upon  them  is  painful.  If, 
however,  the  tension  is  relaxed  by  inclining  the  head  toward  the 
contraction,  movement  of  the  head  in  other  directions  will  be  found 
to  be  practically  unrestricted. 

In  Pott's  disease  the  spasm  of  muscles  is  general,  the  deformity 
is  not  of  a  regular  type,  since  the  chin  often  points  to  the  side 
toward  which  the  head  is  inclined.  Steady  tension  with  the  aim  of 
reducing  the  deformity  is  not,  as  a  rule,  painful;  in  fact,  it  is  often 
agreeable  to  the  patient.  Finally,  the  limitation  of  motion  cannot 
be  lessened  by  inclining  the  head  toward  the  mus':'le  that  seems  to  be 
most  contracted,  for  the  reflex  spasm  of  Pott's  disease  limits  motion 
in  every  direction.  As  a  rule  the  diagnosis  is  easily  made,  but  in 
cases  complicated  by  suppuration  of  the  cervical  glands  it  is  some- 
times impossible  to  exclude  Pott's  disease  until  after  the  effect  of 
treatment  has  been  observed. 

Disease  of  the  cervical  spine,  other  than  tuberculous,  is  compara- 
tively rare,  and  resembles  in  its  symptoms  Pott's  disease  rather  than 
torticollis.  Arthritis  of  the  suboccipital  articulations  may  be  a 
manifestation  of  general  arthritis;  it  may  follow  infectious  disease, 
or  it  may  occur  as  an  isolated  infection.  It  is  of  sudden  onset,  and 
it  resembles  acute  spastic  torticollis,  except  that  all  the  surrounding 
muscles  are  affected  rather  than  a  particular  group;  in  fact,  but  for 
the  history  it  could  not  be  distinguished  from  tuberculous  disease 
of  this  region. 

Although  the  diagnosis  of  torticollis  is  simple,  it  is  not  always 
easy  to  determine  the  muscle  or  muscles  involved  in  the  contraction. 
The  effect  of  unilateral  contraction  of  the  different  muscles  is  as 
follows : 

The  sternomastoid  inclines  the  head  toward  the  contraction, 
displaces  it  toward  the  opposite  shoulder,  elevates  the  chin,  and 
turns  it  away  from  the  contracted  muscle. 

The  trapezius  has  much  the  same  action,  but  the  backward 
inclination  and  rotation  are  more  marked. 

The  action  of  the  complexus  resembles  that  of  the  trapezius,  but 
the  rotation  is  less. 

The  splenius  inclines  the  head  backward  and  toward  the  con- 
tracted muscle,  but  does  not  turn  the  chin  in  the  opposite  direction. 

The  scaleni  have  the  same  action,  except  that  the  head  is  inclined 
forward. 

As  has  been  stated,  in  acute  torticollis  several  muscles  are  often 
involved,  but  the  spasm  is  usually  greater  in  one  or  in  one  group 
than  in  another.  The  seat  of  greatest  contraction  may  be  deter- 
mined by  the  deformity,  by  the  evident  spasm  that  resists  reposi- 
tion, and  by  the  local  sensitiveness  on  palpation.  As  a  rule,  when 
the  primary  contraction  is  of  the  posterior  group  the  deformity  is 
more  marked  than  in  other  forms.  Bilateral  contraction  of  the 
muscles  is  rare,  but  it  is  occasionally  seen  (Fig.  505). 


670  CONGEXITAL  AXD  ACQUIRED   TORTICOLLIS 

Treatment. — The  treatment  varies  according  to  the  cause  and 
with  the  dui-ation  of  the  deformity.  Excluding,  for  the  present, 
the  rare  and  irregular  forms  of  ^^Ty-neck  there  are,  from  the  remedial 
stand-point,  two  forms  of  torticollis: 

1.  The  chronic  form,  in  which  the  local  pain  and  sensitiveness 
are  absent,  but  in  which  there  is  resistant  deformity.  As  has  been 
stated,  congenital  torticollis  is  included  in  this  class. 

2.  The  acute  form,  in  which  the  distortion  is  of  short  duration 
and  in  which  permanent  contraction  may  be  prevented. 

The  Treatment  of  Chronic  Torticollis. — By  Manipulation. — Con- 
genital torticollis,  if  of  moderate  degree,  may  be  overcome  in  early 
infancy  by  methodical  stretching  of  the  contracted  parts.  One  per- 
son fixes  the  arm  and  another  draws  the  head  gently  but  firmly 
in  the  direction  opposed  to  the  contraction,  over  and  over  again, 
meanwhile  massaging  the  tissues  of  the  neck.  The  procedure 
should  be  repeated  several  times  a  day;  it  causes  slight  momentary 
discomfort  if  properly  performed,  but  this  ceases  when  the  stretch- 
ing is  discontinued.  Care  should  be  taken  also  that  posture  may, 
as  far  as  possible,  favor  the  reduction  of  the  deformity;  thus  while 
the  child  is  in  the  mother's  arms  the  head  should  be  supported,  and 
when  asleep  the  pillow  may  be  arranged  in  a  manner  to  prevent  the 
improper  position.  In  this  way  the  torticollis  may  be  entirely  cor- 
rected or  its  progress  may  be  checked  until  more  eft'ective  treatment 
is  indicated. 

Hematoma. — This  should  be  treated  by  massage  with  some  bland 
ointment;  if  it  is  accompanied  by  deformity  the  manipulation 
already  described  should  be  employed. 

In  the  great  majority  of  cases  of  congenital  torticollis  the  patient 
is  not  brought  for  treatment  until  the  deformity  has  become  an  eye- 
sore to  the  parents.  The  contracted  muscle  is  then  usually  an  inch 
shorter  than  its  fellow,  the  disparity  increasing,  as  a  rule,  with  the 
gro^rth  of  the  child.  In  such  cases  the  immediate  correction  of  the 
deformity  is  indicated,  and  this  implies  m  most  instances  division 
of  the  contracted  parts  by  subcutaneous  tenotomy  or  by  open 
incision. 

Subcutaneous  Tenotomy. — If  the  deformity  is  comparatively 
slight  and  if  the  contraction  seems  to  be  limited  to  the  sternomastoid 
muscle,  and  particularly  to  its  sternal  portion,  one  may  hope  to 
overcome  the  most  resistant  part  of  the  contraction  by  the  sub- 
cutaneous operation.  Aside  from  the  possibility  of  wound  infec- 
tion, which  at  the  present  tune  is  an  argmnent  of  very  little  weight, 
subcutaneous  tenotomy  has  the  advantages  of  simplicity,  apparent 
freedom  from  the  danger  which  parents  associate  with  an  operation, 
and  it  leaves  no  scar.  It  is  inadequate,  however,  for  the  correction 
of  advanced  cases. 

The  patient  and  the  instruments  having  been  prepared  as  for  an 
ordinary  operation,  a  sand-bag  is  placed  beneath  the  shoulders  and 


TREATMENT  671 

the  head  is  mdmed  so  that  the  contracted  muscle  is  thrown  into 
reUef  beneath  the  skin.  The  sternal  insertion  of  the  tendon  is 
seized  with  two  fingers  and  the  tenotome  is  inserted  beside  it  and 
passed  beneath  it  at  a  point  about  an  inch  above  the  sternum.  It 
is  then  divided  by  a  sawing  motion  of  the  knife.  Division  of  the 
tendon  in  this  situation  is  practically  free  from  danger,  and  in  the 
slighter  degrees  of  deformity  one  can  by  vigorous  manipulation  and 
forcible  traction  overcome  the  resistance  offered  by  the  other  tissues. 
If  bands  of  fascia  resist  the  correction,  they  may  be  divided  by 
superficial  nicking  with  the  tenotome  in  the  lateral  region  of  the 
neck.  As  a  rule,  however,  in  cases  of  this  type  the  open  incision 
is  to  be  preferred,  as  the  contracted  parts  may  be  divided  without 
danger  of  injury  to  the  bloodvessels  and  nerves  in  this  neighborhood. 

The  Open  Method. — The  skin  should  be  made  tense  by  drawing 
it  upward.  The  incision  should  begin  about  an  inch  above  the 
clavicle,  midway  between  the  clavicular  and  sternal  insertions  of  the 
muscle,  and  pass  downward  and  forward  following  the  natural  folds 
of  the  skin  to  the  clavicle.  In  the  milder  cases  in  childhood  it  need 
be  little  more  than  an  inch  in  length.  A  director  may  be  passed 
beneath  the  sternal  tendon,  and  on  this  it  may  be  divided.  The 
clavicular  insertion  and  the  more  resistant  bands  of  fascia  may  be 
divided  as  they  appear.  The  fascia  and  skin  are  then  carefully 
united  with  fine  catgut. 

In  cases  of  very  great  deformity  in  the  adult  some  of  the  posterior 
as  well  as  the  lateral  muscles  are  involved.  In  such  instances  the 
contracted  parts  may  be  divided  at  the  upper  border  of  the  neck 
through  an  incision  from  the  mastoid  process  backward  along  the 
lower  border  of  the  scalp,  the  scar  being  concealed  by  the  hair. 

Overcorrection  of  the  Deformity. — The  object  of  treatment  is  not 
only  to  correct  the  deformity,  but  also  to  overcome  all  restriction 
of  motion  that  may  remain  after  the  division  of  the  more  resistant 
parts,  and  the  operation,  whether  open  or  subcutaneous,  must  be 
supplemented  by  a  vigorous,  methodical  stretching  of  underlying 
resistant  tissues.  Finally,  the  head  should  be  rotated  in  the  oppo- 
site direction,  the  aim  being  to  completely  overcome  the  secondary 
curvature  of  the  cervical  spine. 

It  may  be  stated  that  Lorenz  considers  it  possible  to  correct 
torticollis,  even  of  long  standing,  by  systematic  kneading  and 
stretching  without  previous  division  of  the  contracted  tissues,  but 
the  use  of  so  much  force  appears  to  be  undesirable  if  by  so  slight  an 
operation  it  may  be  avoided. 

After  all  resistance  to  passive  motion  has  been  overcome  by 
vigorous  manipulation  the  head  should  be  fixed  during  the  process 
of  repair  in  the  overcorrected  position.  Thus  in  the  treatment 
of  typical  torticollis  the  chin  should  be  turned  to  a  point  over  the 
middle  of  the  clavicle  on  the  operated  side,  and  the  head  should  be 
inclined  toward  the  opposite  shoulder,  while  the  neck  is  held  in  the 


672  CONGENITAL  AND  ACQUIRED   TORTICOLLIS 

median  line.  In  this  attitude  a  plaster  bandage  should  be  applied 
surrounding  the  head  and  the  thorax.  It  should  remain  until  all 
local  sensitiveness  has  disappeared,  and  until  the  tendency  toward 
deformity  has  been  checked.  Fixation  in  the  overcorrected  position 
is  very  important  in  childhood,  as  an  aid  in  overcoming  the  deformity 
habit,  but  it  mav  be  dispensed  with  in  the  treatment  of  adults 
(Fig.  508). 

The  plaster  support  is  usually  retained  from  four  to  eight  weeks. 
When  it  is  removed,  massage,  manipulation,  and  g}Tnnastic  train- 
ing are  indicated.     Twice  a  dav  the  head  should  be  forced  to  the 


Fig.  508. — Torticollis,  left,  sho-ndng  the  method  of  fixing  the  head  in  the  overcorrected 
position  after  operation. 

extreme  limit  of  overcorrection.  Traction  on  the  neck  in  self- 
suspension  by  means  of  the  sling  used  in  the  application  of  the 
plaster  jacket,  a  regular  system  of  exercises  for  the  muscles  of  the 
neck  and  back,  and  supervision  of  the  habitual  postures  will  usually 
assure  a  complete  cure.  If,  however,  the  deformity  habit  is  strong 
so  that  the  head  has  a  marked  tendency  to  resume  the  former  atti- 
tude, some  support  is  indicated.  A  simple  and  effective  support 
is  the  jury-mast  as  used  in  the  treatment  of  Pott's  disease  with  the 
plaster  jacket  or  attached  to  a  brace. 

As  has  been  stated,  the  necessity  for  support,  provided  the  deform- 


SPASMODIC   TORTICOLLIS  673 

ity  has  been  thoroughly  overcorrected,  depends  upon  the  care  that 
is  to  be  exercised  in  the  after-treatment.  When  exercises  and  mas- 
sage can  be  efficiently  employed,  the  support  is  not  essential.  In 
other  cases  it  may  be  worn  for  several  months  with  advantage. 

The  principles  of  the  treatment  of  the  chronic  or  painless  form 
of  torticollis  that  have  been  outlined  apply  to  the  acquired  as  well 
as  to  the  congenital  form,  when  adaptive  shortening  has  replaced 
active  contraction.  Acquired  torticollis  is,  in  most  instances, 
however,  a  preventable  deformity;  thus  operative  treatment  would 
be  rarejy  required  had  the  patient  received  proper  treatment. 

The  Treatment  of  Acute  Torticollis. — The  insignificant  form  of  tor- 
ticollis called  stiff  neck  may  be  treated  by  hot  applications;  a  firm, 
wide,  thick  collar  of  flexible  cotton  stiffened  by  several  layers  of 
adhesive  plaster  is  an  agreeable  support  in  the  more  painful  cases. 

In  acute  spastic  torticollis  the  cramp-like  contraction  of  the 
muscles  is  secondary  to  irritation  elsewhere.  This,  if  possible, 
should  be  removed,  and,  as  has  been  stated,  the  general  condition 
of  the  patient  often  requires  treatment  as  well.  But  the  important 
indication  is  to  support  the  head  in  order  to  relieve  the  pain  and  to 
correct  the  distortion.  In  the  early  stage  the  support  of  the  collar 
that  has  been  described  may  be  sufficient,  but,  as  a  rule,  patients  of 
this  class  are  not  seen  untjJLthe  distortion  has  persisted  for  weeks  or 
months  even,  so  that  a  more  efficient  form  of  support  is  required — 
such  is  the  plaster  jacket  and  jury-mast.  The  elastic  tension  of 
this  appliance  overcomes  the  spasm  and  relieves  the  discomfort  and 
apprehension  which  have  lowered  the  vitality  of  the  patient  (Fig. 
41).  If  the  spasm  is  the  result  of  the  irritation  of  enlarged  or  sup- 
purating cervical  glands,  as  is  often  the  case,  the  rest  afforded  by  the 
brace  is  an  effective  treatment  of  the  cause  as  well  as  of  its  effect, 
and  if  suppuration  is  present  this  support  is  most  convenient  for 
the  dressing  that  may  be  required.  When  the  acute  symptoms  and 
the  deformity  have  been  relieved,  manipulation  and  exercises  may 
be  employed  in  the  manner  already  described. 

In  cases  of  longer  standing,  particularly  when  the  posterior 
muscles  are  involved,  the  deformity  may  be  forcibly  corrected 
under  anesthesia,  and  the  head  may  then  be  fixed  in  a  plaster  dress- 
ing in  the  manner  already  described.  This  treatment  may  be 
employed  at  an  earlier  stage  in  selected  cases.  As  a  rule,  when 
deformity  has  been  allowed  to  persist  for  six  months  or  more,  its 
rectification  will  require  division  of  the  more  resistant  tissues. 

Spasmodic  Torticollis. — Spasmodic  torticollis,  a  form  of  convul- 
sive spasm  of  the  muscles  of  the  neck  that  is  somewhat  similar  in 
its  general  characteristics  to  writer's  cramp,  must  not  be  confounded 
with  the  acute  torticollis  of  childhood,  in  which  tonic  spasm  of^the 
affected  muscles,  due  usually  to  some  well-defined  irritation  of  the 
peripheral  nerves,  is  the  characteristic.  Spasmodic  torticollis  is  an 
affection  of  adult  life.  Of  32  cases  collected  by  Richardson  and 
43 


674  CONGENITAL  AND  ACQUIRED   TORTICOLLIS 

Walton/  but  2  were  in  patients  less  than  twenty  years  of  age. 
The  sexes  are  equally  liable  to  the  affection,  and  the  contraction  is 
as  frequent  on  one  side  as  on  the  other. 

The  onset  of  the  affection  is  usually  gradual.  The  first  symptoms 
are  most  often  stiffness  and  discomfort  in  the  muscles  of  the  neck; 
a  "drawing  sensation"  and  a  momentary  twitching  or  slight  con- 
traction which  draws  the  head  to  one  side.  These  sjTiiptoms 
increase  slowly  until  the  head  is  habitually  inclined  in  the  attitude 
of  torticollis.  For  a  time  the  patient  can  correct  the  position 
voluntarily,  or  by  supporting  the  head  with  the  hand  can  restrain 
the  twitching  of  the  muscles,  but  in  w^ell-established  cases  the  head 
is  persistently  inclined  to  one  side  and  the  convulsive  spasm  is  uncon- 
trollable. This  latter  sjonptom  is  the  most  marked  peculiarity  of 
the  affection;  at  intervals  the  muscles  begin  to  twitch,  and  the 
head  finally  drawn  by  the  convulsive  contraction  into  an  attitude 
of  extreme  deformity.  As  the  muscles  most  often  affected  are  the 
sternomastoid  and  trapezius  the  attitude  is  usually  one  of  typical 
torticollis.  The  spasmodic  clonic  contractions  may  involve  the 
muscles  of  the  face  or  of  the  chest  even.  They  are  more  marked 
when  the  patient  is  excited  or  when  sudden  movements  are  neces- 
sary. As  a  rule  patients  complain  of  neuralgic  pain  in  the  head 
and  neck,  aggravated  by  the  cramp-like  contractions. 

Etiology  and  Pathology. — The  etiology-  is  obscm-e.  Many  of  the 
patients  present  a  neurotic  family  or  personal  history,  and  over- 
work, shock  to  the  nervous  system,  and  the  like  are  cited  as  predis- 
posing causes.  The  affection  has  been  compared  to  ^^Titer's  cramp, 
as  in  certain  instances  the  spasm  appeared  to  be  caused  by  con- 
strained positions  of  the  head  necessitated  by  certain  occupations, 
aggravated,  it  may  be,  by  the  strain  of  defective  eyesight. 

The  affected  muscles  may  be  hypertrophied  from  constant 
acti\4ty,  and  in  the  later  stages  of  the  aft'ection  they  are,  as  a  rule, 
permanently  shortened.  No  characteristic  changes  in  the  ner\'es 
or  in  the  central  nervous  system  have  been  recorded. 

Prognosis. — There  is  little  tendency  toward  spontaneous  recovery. 
As  a  rule  the  spasm  becomes  more  constant  and  other  muscles 
become  involved. 

Treatment. — It  is  perhaps  unnecessary  to  state  that  the  general 
condition  of  the  patient  and  the  possible  local  and  general  causes 
of  the  spasm  should  receive  consideration.  As  a  rule,  however, 
the  patient  will  have  exhausted  both  constitutional  and  local  treat- 
ment before  coming  under  observation. 

In  the  mild  and  early  cases  the  avoidance  of  predisposing  causes 
combined  with  massage,  systematic  muscle  training,  and  in  excep- 
tional instances  mechanical  support  may  be  of  service;  but  in  the 
chronic,  severe,  and  persistent  cases  of  this  class  the  resection,  of 

1  Am.  Jour.  Med.  Sc,  January,  1895. 


SPASMODIC  TORTICOLLIS  675 

nerves  supplying  the  affected  muscles  has  alone  proved  to  be  effi- 
cient. If  the  spasm  is  limited  to  the  sternomastoid  and  trapezius 
muscles,  resection  of  the  spinal  accessory  nerve  may  be  sufficient; 
but  if  other  muscles  are  involved  or  if  the  spasm  recurs  after  the 
original  operation,  the  removal  of  the  posterior  branches  of  the  upper 
cervical  nerves,  together  with  extensive  division  of  the  contracted 
muscles  upon  the  same  side  and  sometimes  upon  the  opposite  side, 
also,  may  be  required. 

Resection  of  the  spinal  accessory  nerve  was  first  performed  by 
Campbell  de  Morgan,  of  London,  in  1866,  and  since  then  the  opera- 
tion has  been  repeated  many  times  by  other  surgeons,  with  tem- 
porary or  permanent  benefit  to  the  patients.  According  to  Petit, 
of  26  patients  so  treated  13  were  cured  and  7  were  permanently 
improved.  In  5  others  the  benefit  was  but  temporary,  and  1  died 
from  erysipelas  following  the  operation.^ 

Division  of  Spinal  Accessory  Nerve. — -The  spinal  accessory 
nerve  passes  downward  and  backward  from  the  jugular  foramen 
and  enters  the  anterior  border  of  the  sternomastoid  muscle  at  a 
point  about  one  and  a  half  inches  below  the  tip  of  the  mastoid 
process.  At  this  point  it  should  be  exposed.  Dr.  E.  Eliot,  Jr.,  from 
a  special  study  of  the  course  and  relations  of  the  nerve,  suggests 
the  following  method :  ^ 

"The  incision  should  extend  from  the  mastoid  process  above 
downward  to  one  or  two  inches  beyond  the  angle  of  the  jaw.  The 
anterior  edge  of  the  sternomastoid  should  then  be  exposed.  In  the 
upper  part  of  the  wound  the  posterior  and  inferior  portion  of  the 
parotid  gland  may  have  to  be  drawn  forward,  although  usually 
it  does  not  overlap  the  muscle.  When  this  is  done  it  is  compara- 
tively easy  to  expose  by  blunt  dissection  the  transverse  process  of 
the  atlas,  as  it  lies  directly  below  the  mastoid  process  above,  while 
immediately  in  front  of  this  bony  prominence,  and  running  down- 
ward and  forward  from  the  mastoid  process  toward  the  angle  of  the 
jaw  is  the  posterior  belly  of  the  digastric.  Behind  this  lie  the  main 
vessels  of  the  neck,  with  the  spinal  accessory  nerve  emerging  from 
the  jugular  foramen,  and  the  operator  is  certain  that  no  harm  can 
be  done  to  these  structures  as  long  as  he  remains  superficial  to  the 
digascric  belly,  which  in  its  turn  lies  at  a  considerable  depth — in 
fact,  at  about  the  level  of  the  transverse  process  of  the  atlas. 

"  Owen  and  Petit  have  drawn  attention  to  the  fact  that  the  nerve 
usually  enters  the  mastoid  muscle  at  a  point  opposite  the  angle  of 
the  jaw.  I  have  found,  however,  in  a  large  majority  of  cases  that, 
on  leaving  the  internal  jugular  it  assumes  a  definite  relationship 
with  the  transverse  process  of  the  atlas.  Never  above  it,  sometimes 
directly  over  it,  usually  a  fraction  of  an  inch  in  front  of  its  most 
prominent  part,  the  nerve  may  easily  be  detected  in  the  small 

1  L'Union  Med.,  July  9,  1897.  ^  Ann.  Surg.,  May,  1895. 


G76  CONGENITAL  AND  ACQUIRED   TORTICOLLIS 

amount  of  connective  tissue  that  envelops  it,  and  from  this  point  to 
its  entrance  into  the  belly  of  the  muscle  it  may  be  isolated  with 
safety,  and  treated  by  any  suitable  procedure.  If,  exceptionally, 
it  should  escape  detection  the  anterior  border  of  the  muscle  should 
be  drawn  sharply  backward  at  a  point  opposite  the  angle  of  the  jaw, 
the  nerve  in  this  way  put  on  the  stretch,  and  by  blunt  dissection  in 
the  adipose  tissue  that  separates  the  under  sm-face  of  the  muscle 
from  the  sheath  of  the  vessels  the  nerve  may  be  readily  exposed. 
Usually  the  nerve  passes  from  under  the  posterior  belly  of  the  digas- 
tric, at  a  point  just  in  front  of  the  transverse  process  of  the  atlas,  to 
a  point  on  the  deep  surface  of  the  muscle  just  behind  its  anterior 
margin  opposite  the  angle  of  the  inferior  maxilla.  It  is  sometimes 
accompanied  by  a  small  artery  and  vein,  the  latter  easily  visible, 
the  former  a  branch  of  the  occipital.  Rarely  the  nerve  lies  at  a 
considerable  distance  from  the  transverse  process  of  the  atlas;  in 
1  case  as  much  as  half  an  inch  anteriorly.  Here  the  nerve  could  be 
found  at  its  entrance  into  the  muscle,  the  landmark  of  the  transverse 
process  having  failed  to  localize  its  situation." 

Richardson  suggests  that  if.  the  nerve  is  not  readily  found  its 
position  may  be  ascertained  by  drawing  the  finger-nail  firmly  across 
the  bottom  of  the  wound,  a  sharp  contraction  following  pressure 
upon  it.  The  nerve  having  been  isolated,  a  section  of  an  inch  should 
be  removed.  Richardson  advises  in  addition  vigorous  stretching 
of  both  extremities.  After  division  of  the  nerve  the  spasmodic 
contraction  relaxes  and  the  muscles  become  flaccid,  permitting  the 
normal  position  of  the  head,  or  if  the  deformity  has  become  perma- 
nent the  contracted  parts  may  be  divided  as  in  the  ordinary  form. 
Fixation  of  the  head  is  not,  as  a  rule,  required.  The  operation 
should  be  supplemented  by  massage  and  by  muscle-training.  If  the 
spasm  has  been  confined  to  the  muscles  supplied  by  the  spinal  acces- 
sory nerve,  the  treatment  may  be  permanently  successful,  but  in 
many  instances  the  spasm  may  recur  in  other  muscles.  Of  these, 
the  posterior  group  of  the  opposite  side  is  more  often  affected,  and 
a  similar  operation  for  resection  of  the  posterior  branches  of  the 
upper  cervical  nerves  may  be  indicated.  This  has  been  performed 
with  success  by  Smith,  of  London;  Keen,  Richardson,  and  others. 
According  to  Smith,^  the  operation  should  be  conducted  as  follows: 
An  incision  is  carried  do^Miward  from  the  occiput  about  three  inches 
in  length,  parallel  to  and  one  inch  from  the  spinous  processes.  It  is 
continued  through  the  trapezius  to  the  edge  of  the  splenius. 

The  complexus  is  then  divided  and  the  posterior  branches  of  the 
nerves  are  exposed;  those  of  the  three  upper  ner\'es  which  supply 
the  posterior  rotators  are  then  resected. 

Keen-^  operates  in  a  somewhat  different  manner,  by  a  transverse 
incision  two  and  a  half  inches  in  length  from  the  middle  line  of  the 

Spasmodic  Wry-neck,  London,  1S91.  ^  Ann.  Surg.,  January,  1891. 


SPASMODIC  TORTICOLLIS  677 

neck  on  a  level  with  a  point  one-half  inch  below  the  level  of  the  lobule 
of  the  ear.  The  trapezius  is  divided  transversely,  afterward  the 
complexus,  care  being  taken  to  spare  the  great  occipital  nerve. 
The  posterior  branch  of  the  second  cervical  nerve  is  then  resected, 
the  suboccipital  nerve  is  then  looked  for  in  the  suboccipital  triangle, 
traced  down  to  the  spine,  and  divided.  The  external  trunk  of  the 
posterior  division  of  the  third  occipital  nerve  is  then  exposed  below 
the  great  occipital  and  divided  close  to  the  bifurcation  of  the  nerve 
trunk;  thus  the  nerve  supply  of  the  chief  posterior  rotators,  the 
splenius  capitis,  the  rectus  capitis,  posticus  major,  and  the  obliquus 
inferior  is  removed. 

The  paralysis  that  follows  even  such  extensive  operations  seems 
to  inconvenience  the  patient  but  slightly,  while  the  relief  from 
deformity  and  from  the  constant  spasm  is  a  more  than  sufficient 
compensation  for  whatever  weakness  or  disability  may  result. 

The  following  are  the  conclusions  of  Richardson  and  Walton:^ 

1.  Palliative  treatment,  whether  by  drugs,  apparatus,  or  elec- 
tricity, will  rarely  prove  successful  in  well-established  spasmodic 
torticollis. 

2.  Massage  may  prove  of  value  in  comparatively  recent  cases. 

3.  Resection  affords  practically  the  only  rational  remedy. 

4.  Operation  on  the  spinal  accessory  nerve  may  afford  relief, 
even  if  other  muscles  than  the  sternocleidomastoid  are  affected. 
On  the  other  hand,  the  affection  previously  limited  to  the  sterno- 
cleidomastoid may  spread  to  other  muscles  in  spite  of  this  operation. 

5.  No  fear  of  disabling  paralysis  need  deter  us  from  recommend- 
ing operation,  as  the  head  can  be  held  erect  even  after  the  most 
extensive  resection. 

6.  The  most  common  combination  of  spasm  is  that  involving  the 
sternomastoid  on  one  side  and  the  posterior  rotators  on  the  other, 
the  head  being  held  in  the  position  of  sternomastoid  spasm  with 
the  addition  of  retraction  through  the  greater  power  of  the  posterior 
rotators. 

7.  It  seems  advisable  in  most  cases  to  give  preference  to  the  resec- 
tion of  the  spinal  accessory  as  the  preliminary  procedure. 

In  a  later  communication  Richardson  and  Walton^  report  very 
satisfactory  final  results  on  cases  treated  by  resection  of  nerves  sup- 
plying the  muscles  that  were  affected  by  the  spasm  on  one  or  both 
sides,  combined  with  complete  division  of  the  muscles  as  well, 
when  permanent  contraction  was  present. 

Kalmus^  has  reviewed  the  literature  of  the  subject.  In  11  cases 
of  simple  stretching  of  the  spinal  accessory  nerve  3  were  cured.  In 
68  cases  the  nerve  was  resected;  of  these  23  were  cured  and  20  were 
improved.  In  4  there  was  no  improvement  and  in  1  the  patient 
died.     In  15  cases  the  resection  of  the  nerve  was  supplemented  by 

1  Ann.  Surg.,  January,  1891.  2  Am.  Jour.  Med.  Sc,  1896. 

3  Zur  Operativ  Behand.  Caput.  Obst.  Spasticum,  Beitr.  z.  klin.  Chir.,  1900,  xxiv. 


678 


CONGENITAL  AND  ACQUIRED   TORTICOLLIS 


division  of  cervical  nerves;  10  of  these  were  cured  and  3  were 
improved.     In  2  others  the  sternomastoid  muscle  was  divided. 

Irregular  and  Exceptional  Forms  of  Torticollis. — Paralytic  Torti- 
collis.— One  or  more  of  the  muscles  of  the  neck  may  be  paralyzed, 
as  from  anterior  poliomyelitis,  and  thus  a  deformity,  due  at  first  to 
simple  weakness  and  later  to  the  permanent  effects  of  the  disability, 
may  be  the  result. 

Diphtheritic  Paralysis  and  Torticollis. — The  muscles  of  the  neck  may 
be  involved  in  paralysis  following  diphtheria.  In  this  form  the  tra- 
pezii  muscles  are,  as  a  rule,  affected,  so  that  the  head  droops  for- 
ward, but  occasionally  the  paralysis  may  be  accompanied  by  con- 


FiG.  509. — Cervical  opisthotonos. 

traction  of  one  of  the  sternomastoids.  The  history,  the  evident 
weakness,  and  the  paralysis  of  the  soft  palate  or  other  parts,  which 
is  often  present,  usually  make  the  diagnosis  clear. 

Cervical  Opisthotonos. — In  the  course  of  certain  forms  of  disease 
of  the  nervous  system,  for  example,  cerebrospinal  or  basilar  menin- 
gitis, the  head  may  be  drawn  backward  by  spasm  of  the  posterior 
muscles.  A  slight  degree  of  the  same  deformity  is  sometimes  seen 
in  ill-nourished  infants  not  suffering  from  serious  disease.  This 
and  the  preceding  distortion  are  of  some  importance,  because  they 
may  be  mistaken  for  symptoms  of  Pott's  disease  and  thej^  have 
been  described  in  that  connection. 


IRREGULAR  AND  EXCEPTIONAL  FORMS  OF  TORTICOLLIS     679 

Rhachitic  Torticollis. — During  the  course  of  acute  rhachitis,  par- 
ticularly when  the  characteristic  deformity  of  the  lower  part  of 
the  spine  is  well-marked,  the  head  may  be  tilted  backward  usually 
as  a  compensatory  attitude,  but  occasionally  slight  spasm  of  the 
posterior  muscles  may  increase  the  distortion ;  so,  also,  when  lateral 
deviation  of  the  spine  is  present  due  to  rhachitis  the  neck  may 
participate  in  the  deformity  as  in  other  forms  of  rotary  lateral 
curvature.     This  is  not  torticollis,  however,  in  the  proper  sense. 

Ocular  Torticollis. — The  head  may  be  habitually  held  in  a  dis- 
torted attitude  because  of  defective  vision  or  irregularity  in  the 
action  of  the  muscles  of  the  eyes.  This  is,  however,  rather  an 
improper  attitude  than  a  variety  of  true  torticollis^  (Fig.  204). 

Psychical  TorticoUis.^ — A  distortion  of  the  head,  apparently  due 
to  the  inability  of  the  patient  to  control  the  muscles  of  the  neck, 
has  been  described  by  Brissaud.^  The  deformity  is  not  due  to 
muscular  spasm,  since  it  can  be  corrected  by  the  pressure  of  a  finger 
on  the  head.  The  condition  is  called  by  Brissaud  a  local  paralysis 
of  the  will — a  form  of  neurosis  allied  to  neurasthenia,  epilepsy,  and 
functional  spasm. 

1  Med.  News,  June  11,  1898,  p.  772. 

2  These  de  Paris,  1894. 


CHAPTER  XX. 

DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

GENERAL  DESCRIPTION   OF   THE  FOOT   AND   OF  ITS 
FUNCTIONS. 

The  function  of  the  foot  is  twofold :  to  serve  as  a  passive  support 
of  the  weight  of  the  body,  and  as  an  active  lever  to  raise  and  propel 
it.  For  the  proper  performance  of  these  functions  it  is  constructed 
to  permit  elasticity  under  pressure,  and  an  alternation  of  attitudes 
under  strain,  that  protect  it  from  injury. 

The  Arches. — The  most  noticeable  peculiarity  of  the  foot  is  the 
arrangement  of-  its  arches.  As  has  been  suggested  by  Ellis  and 
others,  the  construction  and  shape  of  the  arched  part  of  the  foot 
may  be  better  understood  by  considering  it  as  half  of  the  arch 


Fig.  510. — Longitudinal  section  of  the  cast  of  the  arch  at  the  point  A  in  Fig.  511. 
A,  the  astragalonavicular  junction;  B,  the  internal  tuberosity  of  the  os  calcis;  C, 
the  head  of  the  first  metatarsal  bone. 

formed  by  the  two  feet.  This  complete  arch  may  be  demonstrated 
by  making  an  imprint  of  the  apposed  feet  in  plaster-of-Paris. 
The  plaster  cast  which  represents  it  will  appear  in  shape  somewhat 
like  an  inverted  saucer,  the  part  of  each  foot  that  rests  upon  the 
ground  forming  half  of  an  irregular  ring.  If  the  plaster  cast  is 
sawed  into  equal  sections  it  will  be  seen  that  the  highest  or  thickest 
part  of  each  division  is  at  the  astragalo-navicular  junction;  from  this 
point  the  arch  descends  sharply  to  the  tuberosities  of  the  os  calcis, 
and  gradually  to  the  outer  border,  beneath  the  cuboid  bone,  and  to 
the  metatarsophalangeal  joints  (Fig.  510).  A  cross-section  of  the 
cast  will  show  the  contour  of  what  is  sometimes  called  the  transverse 
arch  (Fig.  511),  while  the  section  through  the  long  diameter  will 
demonstrate  the  shape  of  the  longitudinal  arch.  In  descriptions  of 
the  longitudinal  arch  it  is  often  divided  into  two  parts,  of  which  the 
outer  division  is  formed  by  the  os  calcis,  the  cuboid,  and  the  two 
outer  metatarsal  bones.     Of  this  outer  arch,  the  highest  point  is  at 


GENERAL  DESCRIPTION  OF  FOOT  AND  ITS  FUNCTIONS     681 

the  calcaneocuboid  articulation  (Fig.  512),  and  although  it  is  normally 
a  permanent  arch,  yet  the  soft  tissues  are  forced  downward  beneath 


Fig.  511. — Cross-section  of  the  cast  of  the  arches  of  the  apposed  feet.    A,  the  internal 
and  inferior  surface  of  the  astragalo-navicular  junction. 

it  when  weight  is  borne,  so  that  the  outer  border  of  the  foot  makes 
an  imprint  throughout  its  entire  length,  as  contrasted  with  the  inner 


-  Fig.  512. — The  bones  of  the  right  foot,  viewed  from  the  outer  side.      (Gerrish's 

Anatomy.) 

and  deeper  arch  formed  by  the  os  calcis,  the  astragalus,  the  navicu- 
lar, the  cuneiform,  and  the  three  inner  metatarsal  bones  (Fig.  513). 


Fig.  513. — The  bones  of  the  right  foot,  viewed  from  the  inner  side.     (Gerrish's 

Anatomy.)  ' 

This  division,  although  an  artificial  one,  serves  to  call  attention  to 
the  fact  that  the  outer  or  lower  arch  is  more  solidly  braced,  and. 


682       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

therefore^  better  adapted  for  continuous  weight-bearing  than  is  the 
higher  and  more  elastic  inner  arch. 

The  diagram  of  the  longitudinal  arch,  showing  its  sharp  descent 
from  the  highest  point  to  the  centre  of  the  heel,  indicates  that  the 
heel  is  well  adapted  for  weight-bearing,  while  the  long  anterior 
pillar  composed  of  several  bones  is  less  strong  but  more  elastic; 
thus  one  instinctively  extends  the  foot  in  descending  stairs,  for 
example,  to  avoid  the  unpleasant  jar  of  direct  shock  received  upon 
the  heel.  Of  this  anterior  pillar,  the  third  metatarsal  bone  is  the 
most  direct  support,  while  the  more  movable  first  and  fifth  meta- 
tarsals, more  under  muscular  control,  aid  in  balancing  the  weight 
and  sustaining  it  in  the  different  attitudes. 

Both  divisions  of  the  longitudinal  arch  are  permanent  arches,  but 
there  are  two  others  which  are  obliterated  under  weight — one  of 
these  is  that  formed  by  the  heads  of  the  metatarsal  bones,  the 
anterior  metatarsal  arch.  In  the  unweighted  foot  the  second  and 
third  metatarsophalangeal  articulations  occupy  a  higher  plane  than 
their  fellows,  but  when  the  erect  posture  is  assumed  the  anterior 
arch  is  depressed  to  allow  the  metatarsal  heads  to  bear  their  share 
of  the  weight.  The  other  arch  is  formed  by  the  internal  border  of 
the  foot,  which  curves  slightly  outward,  so  that  when  the  two  feet 
are  placed  side  by  side  an  interval  remains  between  them,  widest  at 
the  highest  point  of  the  longitudinal  arch,  as  is  shown  in  the  diagram 
by  the  upright  section  which  divides  the  cast  of  the  two  soles  from 
one  another,  the  internal  arch  (Fig.  511).  When  the  weight  is 
borne  this  curved  contour  of  the  foot  becomes  straighter,  or  is 
obliterated,  or  is  even  transformed  to  an  arch  whose  convexity  is 
internal  (Fig.  515). 

The  Foot  as  a  Passive  Support. — The  foot  is  supported  by  the 
muscles,  by  ligaments,  and  by  the  strong  plantar  fascia  that  covers 
in  the  sole.  ^Yhen  the  foot  is  actively  used  it  is  in  great  part  sup- 
ported by  the  muscles,  but  when  it  serves  as  a  passive  support,  as  in 
standing,  the  ligaments  bear  the  greater  part  of  the  strain,  and  its 
normal  elasticity  allows  the  bearing  surface  to  expand  as  the  arches 
are  slightly  depressed.  If  this  elasticity  is  diminished,  the  supports 
of  the  arch  are  subjected  to  abnormal  pressure  and  the  individual 
may  suffer  from  sensiti\'e  corns  or  calloused  skin  beneath  the  bones. 
Or  if  the  ligaments  permit  abnormal  expansion  the  arches  may 
become  permanently  depressed,  and,  as  a  result,  the  range  of 
motion  necessary  to  the  proper  functional  use  of  the  foot  may  be 
permanently  restricted. 

It  has  been  stated  that  the  foot  broadens  and  that  the  arches  are 
slightly  depressed  under  weight;  it  must  not  be  understood,  how- 
ever, that  the  longitudinal  arch  is  simply  flattened  by  direct  pres- 
sure and  by  elongation  of  elastic  ligaments  and  fascia.  Ligaments 
and  fascia  are  not  elastic  in  this  sense,  and  they  are  not,  in  the  nor- 
mal foot,  overstretched.     The  change  in  contour  is  the  effect  of 


GENERAL  DESCRIPTION  OF  FOOT  AND  ITS  FUNCTIONS     683 

normal  motion  in  the  joints  of  the  foot,  by  which  it  is  placed  in  the 
most  favorable  attitude  for  weight -bearing  without  muscular  exer- 
tion— the  so-called  attitude  of  rest. 

Of  the  changes  of  contour  that  distinguish  the  foot  used  as  a 
passive  support  from  one  that  bears  no  weight,  the  most  signifi- 
cant is  the  obliteration  of  the  outward  curve  of  its  internal  border. 
This  change  is  due  to  the  fact  that  the  astragalus,  bearing  the  leg, 
rotates  inward  and  downward  on  the  os  calcis  until  it  is  checked  by 
the  resistance  of  the  ligaments  and  by  the  interlocking  of  the  bones. 
The  head  of  the  astragalus  thus  becomes  slightly  prominent,  the 


Fig.  514.— Illustrating  the  involun- 
tary adduction  of  the  forefoot,  due  to 
the  obliquity  of  the  bearing  surface  of 
the  metatarsus,  in  the  proper  attitude 
for  walking. 


Fig.  515. — The  improper  attitude  of 
outward  rotation  of  the  limbs  usually 
accompanied  by  eversion  of  the  feet 
in  which  there  is  disuse  of  the  leverage 
function. 


inner  border  of  the  foot  is  depressed,  and  an  attitude  is  attained  in 
which  the  weight  of  the  body  may  be  supported  with  but  slight 
muscular  exertion.  In  this  attitude  of  rest,  as  von  Meyer  has 
explained,  there  is  general  fixation  of  joints  of  the  lower  extremity 
which  makes  support  possible  with  the  least  muscular  exertion. 
The  pelvis  tilts  slightly  backward  until  tension  is  brought  upon  the 
anterior  part  of  the  capsule  of  the  hip-joint;  the  femur  rotates 
slightly  inward  on  the  tibia,  which  in  turn  falls  slightly  inward  upon 
the  everted  foot.  To  unlock  the  joints  the  pelvis  must  be  tilted 
forward  or  the  hip  must  be  flexed. 


684       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

The  Foot  in  Activity. — The  second  function  of  the  foot  is  as  a 
lever  to  raise  and  to  propel  the  body.  The  calf  muscles  supply  the 
power  and  the  heads  of  the  metatarsal  bones  serve  as  the  fulcrimi 
on  which  the  weight  is  to  be  lifted.  When  the  foot  is  used  as  a  lever, 
it  should  be  held  in  such  relation  to  the  leg  that  the  line  of  weight, 
passing  downward  through  the  centre  of  the  knee  and  ankle-joints, 
is  continued  over  the  second  toe  or  practically  the  centre  of  the  foot. 
As  the  body  is  lifted  over  the  fulcrum  the  leg  is  turned  outward  in 
its  relation  to  the  forefoot,  because  the  inner  side  of  the  fulcrum, 
formed  by  the  first  metatarsal  bone,  is  longer  than  its  outer  side; 
thus  the  strain  is  directed  toward  the  outer  and  stronger  side  of  the 
foot  (Fig.  514). 

In  the  proper  walk,  which  is  the  best  illustration  of  the  leverage 
function,  the  feet  should  be  held  practically  parallel  to  one  another, 
so  that  the  line  of  strain  may  fall  through  the  centre  of  the  foot. 
As  one  foot  is  advanced  it  first  bears  weight  momentarily  on  the 
heel,  then  upon  its  outer  border;  the  heel  is  then  raised,  and  the 
body  is  lifted  over  the  toes,  the  great  toe  giving  the  final  impulse 
to  the  step,  so  that  if  the  walker  is  looked  at  from  behind  he  appears 
to  be  in-toeing  at  the  termination  of  each  step.  Thus,  during  the 
walk,  there  is  an  alternation  of  postures,  and  the  foot,  under  mus- 
cular control,  assumes  the  attitudes  most  opposed  to  that  of  pas- 
sive support. 

Improper  Postures. — The  alternation  of  postures  and  the  lever- 
age action  of  the  foot  are  by  no  means  necessary  to  simple  progres- 
sion; for  example,  both  feet  might  be  fixed  in  plaster  splints, 
yet  walking  would  be  possible,  just  as  it  is  possible  on  two  wooden 
legs.  Indeed,  an  approximation  to  such  a  manner  of  walking  is 
often  seen,  in  which  the  feet  are  practically  held  in  the  passive 
attitude,  the  weight  beijigJxiine  in  great  part  uj)QiL±hfi  heels^_._.S]iclj 
a  walk  is  necessarily] arriiig  an3"Tnigracefu]7and  if  it  is  not  the 
result  of  weakness  and  deformity  it  dispose~to  them  because  of  the 
disuse  of  proper  function. 

The  custom  of  turning  the  feet  outward  embarrasses  the  leverage 
function.  Outward  rotation  of  the  limbs  is  normal  in  the 
passive  attitude  because  it  enlarges  the  base  of  support  and 
thus  relieves  the  muscles.  On  this  very  account  it  is  the  improper 
attitude  for  activity  because  the  strain  falls  upon  the  inner  border 
of  the  foot,  or  to  the  inner  side  of  the  fulcrum,  and  makes  the 
proper  exercise  of  muscular  power  and  alternation  of  postures  impos- 
sible. In  other  words,  the  attitude  normal  when  the  foot  is  used  as 
a  passive  support  is  abnormal  when  it  is  in  active  use. 

The  Movements  of  the  Foot. — The  junction  between  the  foot 
and  the  leg  is  made  by  means  of  the  astragalus,  a  bone  which  is  not 
intimately  connected  with  either  part,  since  it  moves  upon  the  leg 
and  upon  the  foot,  and  to  it  no  muscles  are  attached. 

The  primary  movements  of  the  foot  are  four  in  number — dorsal 
flexion,  plantar  flexion,  adduction,  abduction. 


Fig.  516. — Voluntary  dorsal  flexion  Fig.  517. — Voluntary  plantar  flexion. 

Figs.  516  and  517. — In  these  attitudes  the  astragalus  moves  with  the  foot  upon  the 
leg  bones,  as  contrasted  with  adduction  and  abduction,  in  which  the  centre  of  motion 
is  below  the  astragalus. 


Fig.  518. — Voluntary  adduction.  Fig.  519. — Voluntary  abduction. 

Figs.  518  and  519. — In  these  postures  the  foot  moves  upon  the  astragalus,  which 
is  practically  fixed  between  the  malleoH.  Adduction,  the  turning  of  the  foot  inward 
in  its  relation  to  the  leg,  is  always  accompanied  by  elevation  of  its  inner  and  depres- 
sion of  its  outer  border.  This  is  known  as  supination  or  inversion  of  the  foot.  The 
reverse  of  this  attitude — pronation  or  eversion — is  an  accompaniment  of  abduction, 
as  is  illustrated  in  the  figures. 


686       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

Simple  dorsal  and  plantar  flexion  are  confined  to  the  ankle-joint, 
but  extreme  plantar  flexion  is  combined  with  slight  adduction,  and 
dorsal  flexion  with  abduction,  because  the  external  facet  of  the 
astragalus  permits  a  greater  range  of  motion  on  the  external  mal- 
leolus than  that  about  the  internal  malleolus,  and  because  the  fore- 
foot in  plantar  flexion  turns  downward  and  inward  on  the  head  of 
the  astragalus  and  in  the  reverse  direction  in  dorsal  flexion. 

The  range  of  motion  at  the  ankle-joint  is  from  60  to  80  degrees; 
thus  dorsal  flexion  to  10  to  20  degrees  less  than  the  right  angle,  and 
plantar  flexion  to  50  to  60  degrees  more  than  the  right  angle  (Figs. 
517  and  518). 


Fig.  520. — Tibialis    anterior    of    right         Fig.  521. — Peroueus  tertius  of  right  side; 
side;  outline  and  attachment  areas.  outline  and  attachment  areas. 

Figs.  520  and  521. — The  direct  dorsal  flexors. i 


.^^  Adduction  and  abduction  of  the  foot  are  carried  out  in  the  medio- 
tarsal  and  subastragaloid  joints. 

Adduction,  the  turning  of  the  foot  inward  in  its  relation  to  the 
leg,  is  always  accompanied  by  inversion  of  the  sole  because  of  the 
shape  of  the  joint  surfaces  between  the  astragalus  and  os  calcis, 
where  the  greater  part  of  the  motion  takes  place.  Simple  adduc- 
tion and  abduction  without  inversion  or  eversion  is  possible  to  a  very 
limited  extent  in  the  mediotarsal  joint.  Its  range  may  be  tested 
by  fixing  the  heel,  when  the  forefoot  may  be  mo\'ed  slightly  from 
side  to  side  upon  the  astralgalus  and  os  calcis.  The  range  of  motion 
in  the  subastragaloid  joint  is  twice  as  free  as  in  the  mediotarsal 
joint.  The  character  of  the  motion  between  the  astragalus  and  os 
calcis  is  rotation  on  an  axis  passing  tlirough  the  upper  and  inner 

1  Figs.  520-530  modified  from  Gerrish. 


GENERAL  DESCRIPTION  OF  FOOT  AND  ITS  FUNCTIONS     687 

part  of  the  head  of  the  astragalus,  downward  and  outward  to  the 
outer  tuberosity  of  the  os  calcis.  Thus  for  all  practical  purposes 
adduction,  inversion,  and  supination  are  synonymous  terms,  as  are 
abduction,  eversion,  and  pronation. 

In  the  movement  of  inversion  the  astragalus  is  practically  fixed 
by  the  malleoli,  and  upon  it  the  os  calcis  glides  forward,  its  anterior 
extremity  turning  slightly  inward;  its  inner  superior  surface  is 
elevated,  and  its  external  surface  is  depressed.  Meanwhile  the  fore- 
foot, attached  to  the  os  calcis,  is  carried  inward  and  downward 
about  the  head  of  the  astragalus;  its  inner  border  is  elevated,  and 


Fig.  522. — The  gastrocnemius  of  right  Fig.  523. — The  soleus   of  right  side; 

side;  outline  and  attachment  areas.  outline  and  attachment  areas. 

Figs.  522  and  523. — The  combined  soleus  and  gastrocnemius  is  called  the  calf  muscle. 


its  outer  border  is  repressed,  so  that  the  sole  looks  inward  and 
downward.  In  this  attitude  all  the  arches  are  increased  in  depth 
(Fig.  518). _ 

In  eversion  the  bones  move  upon  one  another  in  the  reverse 
direction,  the  curves  are  lessened,  and  that  of  the  inner  border  is 
obliterated  (Fig.  519). 

Simple  inversion  and  eversion  can  be  carried  out  to  the  full  extent 
with  the  foot  at  a  right  angle  to  the  leg.  Complete  adduction, 
however,  is  only  attained  in  the  position  of  plantar  flexion.  In  this 
position  the   forefoot  is  flexed  over  the   head  of  the  astragalus, 


688       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

increasing  the  depth  of  the  arch  and  the  adduction  permitted  at  the 
ankle-joint  when  the  narrow  posterior  border  of  the  astragalus  is 
alone  in  contact  with  the  malleoli,  is  added  to  the  adduction  which 
the  joints  of  the  foot  permit. 

Extreme  abduction  is  attained  in  the  attitude  of  dorsal  flexion, 
its  extent  being  about  one-half  that  of  adduction;  the  entire  range 
of  motion  between  the  two  extremes  being  about  45  degrees. 

In  this  description  the  foot  is  considered  as  moving  on  the  leg, 
but  in  the  attitude  of  rest  the  foot  becomes  the  fixed  point  and  the 
astragalus  moves  upon  the  os  calcis  in  the  manner  and  to  the  posi- 
tion already  mentioned  in  the  description  of  abduction — i.  e.,  it 
slips  downward  and  forward  and  turns  inward;  at  the  same  time  the 


Fig.  524. — Peroneus    longus     of    right         Fig.  525. — Peroneus  brevis  of  right  side ; 
side;  outUne  and  attachment  areas.  outUne  and  attachment  areas. 

Figs.  524  and  525. — The  direct  abductors. 


anterior  extremity  of  the  os  calcis  tiu"ns  slightly  inward  and  down- 
ward, and  its  inner  border  is  depressed.  Corresponding  to  this 
movement,  as  the  inner  border  of  the  foot  becomes  straight  or 
bulges  inward,  the  navi:;ular  is  forced  forward  and  downward  and 
the  longitudinal  arch  is  depressed.  As  has  been  mentioned,  the 
turning  of  the  leg  inward  and  the  corresponding  turning  of  the  foot 
outward  in  its  relation  to  it  locks  in  a  manner  the  ankle-joint,  and 
at  the  same  time  throws  the  strain  upon  the  ligaments,  so  that 
standing  in  the  erect  posture  is  possible  with  but  little  muscular 
exertion  (Fig.  531). 

To  put  in  a  simpler  manner,  the  leg  supporting  the  weight  of  the 
body  has  a  tendency  to  tilt  the  foot  over  toward  the  inner  side  and 
to  evert  the  sole ;  thus,  under  increasing  weight,  the  point  of  great- 


GENERAL  DESCRIPTION  OF  FOOT  AND  ITS  FUNCTIONS     689 


est  pressure  on  the  sole  shifts  from  its  centre  and  outer  border 

toward  the  inner  border.     If,  on  the  other  hand,  the  body  is  raised 

upon  the  toes,  the  arch  is  reheved  from 

strain  and  the  weight  falls  upon  the  front 

and  outer  part  of  the  foot.     Plantar  flexion 

and  adduction    represent,    as    contrasted 

with  the  passive    attitude  of  supporting 

weight,  the  attitude  of  activity  in  which 

the  foot  is   supported  and  controlled  by 

the  muscles. 

The  Functionof  the  Muscles. — The  most 
important  function  of  the  dorsal  flexors  is 
to  raise  the  foot  as  it  is  swung  forward;  of 
the  plantar  flexors  to  lift  and  propel  the 
body.  The  difference  in  function  is  shown 
by  the  relative  strength  of  the  two  groups, 
the  plantar  flexors  being  five  times  the 
stronger;  in  fact,  the  calf  muscle  (gastroc- 
nemius and  soleus)  alone  is  three  times  as 
powerful  as  all  the  other  muscles  of  the 
foot  combined.  It  is  practically  the  lever- 
age muscle,  the  others  serving  more  espe- 
cially to  balance  the  foot  and  hold  it  in  its 
proper  relation  to  the  leg.  It  is  also  a 
powerful  adductor  and  invertor  of  the  foot 
in  the  attitude  of  plantar  flexion  (Figs. 
522  and  523). 

The  muscles  that  niore  directly  support 
the  inner  arch  of  the  foot  are  the  tibialis 
posticus  and  tibialis  anticus,  whose  tendons 
approach  to  then-  attachments  in  front  of 
the  astragalus.  The  tibialis  anticus  sup- 
ports the  internal  border  of  the  foot  from 

above,  and  is  the  direct  invertor  of  the  foot  in  dorsal  flexion — that  is, 
if  unopposed  it  elevates  the  inner  border  of  the  foot,  when  it  acts  as 
a  dorsiflexor.  The  tibialis  posticus  is  the  most  powerful  adductor 
(Figs.  520  and  526) .  The  extensor  longus  hallucis  is  an  adjunct  of 
the  tibialis  anticus  in  its  action  on  the  foot  as  a  whole.  The  ex- 
tensor longus  digitorum,  including  the  peroneus  tertius,  is  a  dorsal 
flexor  and  abductor. 

The  flexor  longus  hallucis,  passing  directly  beneath  the  susten- 
taculum tali,  aids  in  supporting  the  weak  part  of  the  foot  and  its 
position  demonstrates  the  importance  of  the  proper  functional  use 
of  the  great  toe  (Fig.  530). 

The  peroneils  longus  and  brevis  support  the  outer  arch,  and  the 
former  binds  the  foot  together  and  holds  the  great  toe  firmly  against 
the  ground;  thus  it  indirectly  supports  the  longitudinal  arch  against 
direct  pressure  (Figs.  524  and  525). 
44 


Fig.  526.— The  most  im- 
portant adductor.  Tibialis 
posterior  of  right  side;  out- 
Hne  and  attachment  areas.- 
The  most  of  the  muscle  is 
represented  as  if  seen  through 
the  bones. 


C90       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


Fig.  527. — Extensor  proprius  hallucis 
of  right  side;  outline  and  attachment 
areas. 


Fig.  528.  —  Extensor  longus  digi- 
torum  of  right  side:  outline  and  attach- 
ment areaf. 


Fig.  529. — Flexor  longus  digitorum  of 
right  side;  outline  and  attachment  areas. 
The  muscle  is  represented  as  seen  from  in 
front   through  the  Ijones. 


Fig.  530. — Flexor  longus  hallucis 
of  right  side;  outline  and  attachment 
areas.  The  muscle  is  represented  as 
seen  from  the  front  through  the  bones. 


GENERAL  DESCRIPTION  OF  FOOT  AND  ITS  FUNCTIONS     691 

The  peroneus  loiigus  is  an  abductor,  the  brevis  a  more  direct 
evertor  of  the  foot. 


Fig.  531. — An  attitude  that  simulates  the  Fig.  532. — Compared  with  Fig.  531 

flat-foot.      (See  Fig.  533.)  illustrates    the    voluntary    protection 

of  the  foot  from  overstrain. 

The  relative  strength  of  the  muscles  and    their    functions    is 
indicated  in  the  following  tables:^ 

Dorsal  Flexors  of  the  Foot;  Strength   Reckoned  in  Kilogrammeters. 

Tibialis  aiiticus 0.871 

Extensor  longus  digitorum 0 .  280 

Extensor  longus  pollicis         .  ' 0 .  155 

Peroneus  tertius 0 .  087 

1.393 
Plantar  Flexors. 

The  calf     fSoleus 3.256 

muscle.      \  Gastrocnemius 2.831 

Flexor  longus  pollicis 0.218 

Peroneus  longus 0.118 

Tibialis  posticus 0 .  094 

Flexor  longus  digitorum 0 .  078 

Peroneus  brevis 0 .  055 

6.650 

1  R.  Fick:  Ueber  die  Arbeitsleistung  der  auf  die  Fussgelenke  Wirkenden  Muskeln, 
Leipzig. 


692       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

The  Foot  Considered  as  a  Mechanism. — In  the  study  of  the 
deformities,  and  particularly  of  the  functional  weaknesses  of  the 
foot,  one  must  never  lose  sight  of  the  fact  that  it  is  a  mechanism, 
and  that  its  deformities  and  disabilities,  its  relative  strength  or 
■weakness,  can  be  appreciated  only  by  comparing  it  with  the  normal 
standard.  ^Marked  deformity  or  distortion  is  evident  at  a  glance, 
even  though  the  apparatus  is  not  in  use,  but  functional  ability  can 
be  estimated  only  by  the  manner  in  which  active  work  is  performed. 

As  has  been  stated,  the  foot  is,  in  activity,  a  lever,  by  means  of 
which  the  weight  of  the  body  is  lifted  and  propelled.  If  it  is  loosely 
constructed  or  insufficiently  supported  by  the  ligaments,  it  cannot 
be  properly  controlled  by  the  muscles.  If,  on  the  other  hand,  the 
muscular  power  is  insufficient,  the  weight  of  the  body  cannot  be 
lifted  and  properly  balanced  upon  it.  The  structure  of  the  foot 
may  be  normal,  and  its  muscles  may  be  of  normal  strength,  yet  the 
strain  placed  upon  it  may  be  disproportionately  great.  The  strain 
may  be  overweight  of  body,  or  the  overwork  of  a  laborious  occupa- 
tion, but  more  often  the  foot  is  overworked  because  it  is  weakened 
by  compression  and  consequent  distortions  and  because  it  is  sub- 
jected to  mechanical  disadvantages  in  the  performance  of  its  func- 
tions, by  the  assumption  of  improper  attitudes. 

One  of  the  most  common  of  such  attitudes  is,  as  has  been  men- 
tioned, that  of  turning  the  feet  outward  in  walking;  for  as  the  ful- 
crum is  displaced  outward,  the  strain  falls  through  the  inner  and 
weaker  side  of  the  foot.  As  a  consequence  there  is,  to  a  greater  or 
less  degree,  disuse  of  the  active  leverage  function,  the  foot  being 
used  somewhat  as  if  it  were  a  movable  pedestal.  (Fig.  514.)  This 
posture  is  usually  associated  with  abduction  of  the  foot,  the  passive 
attitude  that  predisposes  to  pain  and  weakness. 

The  disuse  of  the  active  function  may  be  unnecessary,  just  as  the 
outward  rotation  of  the  limbs  with  which  it  is  associated  is  a  habit, 
a  habit  that  is  often  the  result  of  improper  teaching.  On  the  other 
hand,  the  habitual  assumption  of  the  passive  attitude  may  be 
induced  by  injury  or  disease  of  the  foot,  or  by  corns  or  bunions,  or 
by  improper  shoes.  For  under  such  conditions  the  strain  of  the 
leverage  function  increases  the  discomfort;  consequently  it  is  dis- 
continued. It  must  not  be  inferred  that  such  improper  attitudes 
lead  inevitably  to  weakness  and  discomfort,  for  in  most  instances 
an  ungraceful  carriage  and  gait  are  the  only  ill  effects.  The 
improper  attitudes  must,  however,  lessen  the  power  and  resistance 
of  the  foot,  and  they  must  be  reckoned,  therefore,  among  the  impor- 
tant predisposing  causes  of  disability. 

The  passive  attitude,  it  will  be  remembered,  is  the  attitude  of 
abduction  or  rest,  in  which  the  ligaments  bear  the  greater  part  of 
the  strain  and  in  which  the  arches  of  the  foot  are  depressed  or 
obliterated. 


THE   WEAK  FOOT 


693 


THE  WEAK  FOOT. 

Synonyms. — Splay-foot,  flat-foot,  pronated  foot. 

The  introductory  pages  of  this  chapter  lead  naturally  to  the  con- 
sideration of  the  most  important  of  the  acquired  disabilities  of  the 
foot,i  a  disability  whose  characteristic  in  the  mildest  and  in  the  most 
advanced  type  is  the  persistence  of  the  passive  attitude  of  abduction, 
or  an  approximation  to  it,  in  place  of  normal  alternation  of  posture. 
Disuse  of  function  is  followed  by  restriction  of  motion,  particularly 
in  theTange  of  adduction  and  plantar  flexion,  and  finally  by  deform  i- 
ity,  a  deformity  that  is  simply  an  exaggeration  of  the  normal  posture 
assumed  when  the  foot  supports  weight  (Fig.  531).  This  is  the  so- 
called  flat-foot  (Fig.  533) .  At  first  glance  it  may  seem  that  the 
depression  of  the  arch  is  the  most 
noticeable  peculiarity  in  a  char- 
acteristic case  of  flat-foot,  and  that 
the  popular  name  is  therefore 
an  appropriate  one.  On  closer  ex- 
amination, however,  it  will  appear 
that  the  foot  is  not  flat  because  its 
"  keystone  has  sunk,"  but  that  the 

lowered  arch  is  caused  by  lateral  ' 

displacement     (abduction) .     This  ^ 

fact    may    be  demonstrated    by  ^^m^M 

adducting  the  foot  sufficiently  to 
restore  approximately  the  normal      ^^ 
relation  between  it  and  the  leg, 
a  movement  which  will  restore  its        Fig.  533.— Typical    "flat-foot"    of 

1  ,  moderate  degree,  illustrating  the  com- 

normal  contour.  ponent     elements     of    abduction     and 

The    deformity   then    may   be     depression  of  the  arch, 
analyzed  as  follows : 

(1)  The  leg  is  displaced  inward,  so  that  the  weight  falls  upon  the 
inner  side  of  the  foot.  (2)  The  leg  is  rotated  inward  so  that  a  line 
drawn  through  its  centre,  prolonged  from  the  crest  of  the  tibia, 
instead  of  falling  over  the  second  toe,  now  points  inside  the  great 
toe,  or  even  over  the  centre  of  the  internal  border  of  the  foot  (Figs, 
533  and  536). 

It  has  been  stated  that  under  normal  conditions,  in  the  act  of 
passive  weight-bearing,  the  astragalus  rotates  downward  and  inward 
upon  the  os  calcis,  depressing  its  anterior  and  internal  border  until 
the  movement  is  checked  by  the  strong  ligaments  connecting  the 
bones,  the  calcaneonavicular,  the  deltoid,  and  the  interosseus;  in 
other  words,  in  the  passive  attitude  the^leg  has  a  tendency  to  slip 
downward    and    inward  from  off  the  fooE     In  the~weak'^foot    of 

1  In  1915,  2134  new  cases  of  weak  foot  were  registered  in  the  outpatient  depart- 
ment of  the  Hospital  for  Ruptured  and  Crippled  in  a  total  of  8604  new  patients, 
24.6  per  cent. 


694       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

advanced  grade  this  simulating  attitude  has  become  an  actual 
deformity,  for  the  normal  movement  has  become  so  exaggerated  by 
the  distention  of  the  ligaments  and  by  the  ^^'eakness  of  the  support- 
ing muscles  that  an  actual  subluxation  is  present.  The  astragalus 
has  rotated  and  slipped  far  to  the  inner  side  of  its  normal  position, 
to  an  attitude  of  exaggerated  rotation  and  plantar  flexion,  so  that 
its  head  can  be  plainly  felt  on  the  internal  border  of  the  foot.  The 
anterior  extremity  of  the  os  calcis  is  depressed  and  is  turned  slightly 
inward  and  its  internal  border  is  lowered  (Fig.  535), 

The  navicular  has  been  depressed  with  the  head  of  the  astragalus, 
although  to  a  less  degree,  it  has  been  forced  farther  away  from  the 
OS  calcis,  and  the  entire  inner  border  of  the  foot  is  lowered.  Thus 
the  depression  of  the  arch  is  always  accompanied  and  preceded  by  a 
bulging  inward  of  the  inner  side  of  the  foot. 

The  typical  flat-foot  is,  as  it  were,  broken  in  the  centre  (Fig. 
533),  the  posterior  division  having  turned  inward  and  downward, 
while  the  forefoot  is  forced  downward  and  outward.     The  disloca- 


FlG. 


534. — The  relation  of  the  astrag- 
alus to  the  OS  calcis. 


Fig.  535. — The   relation  of  the  astrag- 
alus and  OS  calcis  in  fiat-foot. 


tion  may  be  so  extreme  that  the  entire  sole  of  the  foot  rests  upon 
the  ground,  and  a  callus  even  may  be  found  at  the  point  that  usually 
represents  the  highest  point  of  the  arch,  which  now  supports  the 
greatest  biu-den. 

In  this  change  of  relation  between  the  bones  the  arched  part  of 
the  foot  or  waist  appears  much  broader  than  normal,  even  broader 
than  the  front  of  the  foot;  the  heel  projects,  the  external  malleolus 
is  depressed  and  carried  forward  by  the  rotation  of  the  leg,  and  is 
much  less  prominent  than  normal;  the  internal  malleolus  is  more 
prominent,  and  with  the  astragalus  it  overhangs  the  bearing 
surface  of  the  sole.  The  entire  mechanism  is  out  of  gear;  its 
motion  is  therefore  very  much  restricted.  It  is  manifestly  impos- 
sible for  the  patient  to  adduct  the  forefoot — that  is,  to  turn  it 
inward  about  the  head  of  the  displaced  astragalus.  Plantar  flexion 
is  also  much  limited,  because  of  the  persistent  adduction  and  plantar 
flexion  of  the  astragalus.  Dorsal  flexion,  on  the  other  hand,  even 
if  actually  restricted,  may  appear  to  be  abnormally  free,  because 


THE  WEAK  FOOT 


695 


the  forefoot  is  abducted  and  slightly  dorsiflexed  upon  the  head  of  the 
astragalus  (Fig.  533). 

The  disability  and  its  accompanying  deformity  are  found  in  every 
grade  of  severity.  Discomfort  usually  begins  when  the  strain  upon 
the  muscles  is  disproportionate  to  their  strength,  and  it  is  increased 
when  the  ligaments  begin  to  give  way  under  strain,  allowing  the 
bones  to  occupy  an  abnormal  relation  to  one  another.  It  is  evident, 
therefore,  that  the  individual  in  whose  foot  the  arch  is  well-formed 

and  whose  ligaments  are  firm, 
will  suffer  from  the  symptoms 
of  strain  long  before  the  arch 
has  been  depressed,  also,  that 
the  lateral  inward  bulging, 
characteristic  abduction,  must 


Fig.  536. — -Weak  feet,  showing  the 
inward  rotation  of  the  legs  when  the 
abducted  feet  are  placed  side  by  side, 
indicating  an  attitude  of  persistent 
abduction. 


Fig.  537. 


-Weak  feet,  arches  not  de- 
pressed. 


be  very  great  before  the  arch  is  completely  flattened.  In  this  type 
the  prominent  deformity  is  lateral  displacement  (valgus).  On  the 
other  hand,  if  the  individual  has  inherited  a  low  arch,  or  if,  as  the 
result  of  weakness  in  early  life,  the  arch  has  been  depressed  or  has 
never  formed,  accommodative  changes  in  the  joints  will  have  taken 
place  during  growth,  so  that  the  flat-foot  of  this  type  will  not  be 
attended  with  as  much  change  in  its  relation  to  the  leg,  and,  there- 
fore, disturbance  of  function,  as  in  the  typical  case  that  has  been 


696       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

described.  This  latter  class  of  cases  exemplifies  the  popular  type  of 
flat-foot  that  may  exist  without  pain  or  disability,  and  in  which  the 
most  noticeable  peculiarity  is  the  obliteration  of  the  arch  (planus). 
(Contrast  Figs.  538  and  539.) 

In  certain  instances  abnormal  laxity  of  ligaments  permits  deform- 
ity of  the  valgus  type  when  weight  is  borne,  yet  the  foot,  controlled 
by  efficient  muscles,  may  be  apparently  normal  in  functional  ability, 
while  in  other  cases  in  which  the  ligaments  are  normal  and  yet  are 
subjected  by  insufficient  muscular  protection  to  overstrain,  disability 
and  pain  may  precede  noticeable  deformity. 

It  is  evident  that  the  lowering  of  the  arch  is  of  secondary  impor- 
tance in  the  deformit}',  and  that  the  popular  significance  of  flat-foot, 
as  an  inherited  or  irremediable  weakness,  is  most  misleading.  Yet 
it  seems  to  have  governed  the  treatment  of  the  disability  until  very 
recently.  On  the  one  hand,  the  early  cases  were  overlooked  because 
the  foot  was  not  flat,  while  those  in  which  the  deformity  was  more 
advanced  were  either  neglected  or  w^ere  treated  by  simple  supports 
beneath  the  arch  or  by  operation,  without  regard  to  the  loss  of  func- 
tion, and,  therefore,  without  hope  of  ultimate  cm"e. 

As  has  been  stated,  there  is  one  feature  common  to  every  grade 
of  the  so-called  flat-foot:  the  foot  regarded  as  a  mechanism  is  weak 
as  compared  to  the  normal  standard — weak  because  of  the  persist- 
ence of  the  attitude  of  rest  and  relaxation,  as  contrasted  with  that 
of  activity  and  strength,  and  weak  because  the  proper  relation 
between  the  power  and  the  fulcrum  is  changed.  Even  the  inherited 
flat-foot  or  the  flat-foot  wdiich  has  never  caused  symptoms  is  weak 
in  the  sense  that,  in  use,  it  lacks  the  symmetry  and  elasticity  char- 
acteristic of  the  perfect  machine.  The  term  weak  foot  may  be  used, 
then,  to  include  all  t^^es  of  the  disability. 

In  one  weak  foot  the  arch  has  disappeared  (Fig.  533) ;  in  another 
it  is  lowered;  in  a  third  the  arch  is  of  normal  depth  (Fig.  537).  In 
one  case  the  deformity  appears  only  under  weight -bearing;  in 
another  the  foot  is  held  rigidly  in  the  deformed  position  by  muscular 
spasm.  In  one  instance  there  may  be  great  deformity  without  pain; 
and  in  another  disabling  weakness  and  pain  without  noticeable 
deformity.  In  one  case  the  foot  is  unable  to  perform  its  functions 
because  of  its  inherent  weakness;  in  another  the  disability  may  be 
due  simpl}'  to  the  improper  use  of  a  normal  structure  but  there  is 
one  characteristic  common  to  all,  a  persistence  of  the  passive  atti- 
tude of  abduction. 

Etiology. — The  early  symptoms  are  caused  by  fatigue  and  strain 
of  the  muscles  working  at  a  disadvantage,  and  the  later  symptoms 
are  explained  by  the  injury  to  which  the  overstrain  has  subjected 
the  mechanism. 

This  theory  accounts  for  the  fact  that  the  weak  foot,  although 
very  common  in  childhood,  does  not,  as  a  rule,  cause  disability 
until  adolescence,  when  the  weight  and  strain  put  upon  it  are 


THE  WEAK  FOOT  697 

increased.  It  explains  why  the  foot,  which  may  be  fairly  normal 
in  structure,  breaks  down  often  in  later  adolescence  or  early  adult 
life  when  the  continuous  strain  of  regular  occupation  is  undertaken. 
It  is  evident,  also,  that  an  occupation  that  induces  a  persistence  of 
the  passive  attitude,  that  of  waiters,  cooks,  and  bartenders,  for 
example,  exposes  the  feet  to  greater  strain  than  one  which  encourages 
alternation  of  postures.  And  that  the  symptoms  are  likely  to  be 
more  severe  and  the  deformity  to  be  greater  among  those  who  are 
obliged  to  labor  than  among  those  who  are  not.  Overwork  or 
strain,  of  occupation  or  otherwise,  may  be  temporarily  dispropor- 
tionate because  of  general  weakness,  as,  for  example,  during  preg- 
nancy or  after  recovery  from  exhausting  disease;  or  because  of 
local  injury  or  disease  of  the  foot  itself,  which  weakens  it  directly 
or  indirectly  by  inducing  improper  attitudes.  This  theory  explains 
why  there  is  no  constant  relation  between  the  degree  of  deformity 
and  the  severity  of  the  symptoms,  for,  although  all  weak  feet  are 
mechanically  weak,  yet  all  weak  feet  are  not  necessarily  painful  or 
deformed.  Pain  is  not  caused  because  the  foot  is  flat  or  because  it 
is  improperly  used;  it  is  a  symptom  of  strain  and  injury  and  of 
progressive  deformity.  The  progress  of  the  deformity  may  be 
temporarily  or  permanently  checked  at  any  stage,  either  by  removal 
of  the  exciting  causes  or  because  of  the  increased  resistance  of  the 
tissues;  then  the  pain  intermits  or  ceases. 

This  conception  of  the  foot  as  a  mechanism,  of  which  grades  of 
efficiency  may  be  recognized,  has  a  great  advantage,  since  it  enables 
one  to  perceive  wherein  a  foot  is  weak,  even  though  the  weakness 
causes  no  symptoms  whatever,  and  thus  to  prevent  discomfort  and 
deformity  by  the  recognition  and  treatment  of  its  predisposing 
causes. 

Statistics. — A  brief  analysis  of  1000  cases  of  so-called  flat-foot 
treated  at  the  Hospital  for  Ruptured  and  Crippled  will  represent 
fairly  the  points  of  general  interest  in  this  class  of  cases : 

The  Age  and  Sex  of  the  Patients. 

Males.  Females.  Total. 

Ten  years  or  less 68  30  98       ' 

Ten  to  fifteen 112  87  199 

Fifteen  to  twenty 144  83  227 

Twenty  to  twenty-five 94  53  147 

Twenty-five  to  thirty 68  41  109 

More  than  thirty 132  88  220 

618  382  1000 

Foot  affected:  right,  133;  left,  138;  both,  729. 

In  58  cases  the  cause  of  the  disability  appeared  to  be  injury,  and 
in  65  instances  it  was,  apparently,  due  to  the  so-called  rheumatoid 
diseases.  The  symptoms  usually  appear  first  in  one  foot,  and,  as  a 
rule,  there  are  at  all  times  more  marked  on  one  side.     Of  569 


698       DISABILITIES  AXD  DEFORMITIES  OF   THE  FOOT 

instances,  in  ^\  hicli  tiie  duration  of  symptoms  was  recorded,  it  was 
six  months  or  less  in  409. 

Hospital  statistics  cannot  adequately  represent  the  subject,  for, 
as  a  rule,  it  is  because  of  disability  and  pain  that  these  patients 
apply  for  treatment.  In  a  large  proportion  of  the  cases  recorded 
muscular  spasm  and  stiffness  were  present,  in  234  instances  to  such 
a  degree  that  forcible  overcorrection  was  advised — an  operation 
rarely  necessary  in  private  practice. 

It  is  in  childhood  that  the  prevention  of  subsequent  weakness 
and  deformity  is  of  the  first  importance,  yet  but  98  children  of  ten 
years  of  age  or  less  are  recorded,  and  many  of  these  were  brought, 
not  for  weakness  or  deformity,  but  for  treatment  of  the  symptomatic 
in-toeing. 

It  may  be  noted  that  in  more  recent  statistics  than  the  above 
which  were  compiled  for  the  ibst  edition  of  this  work,  the  disability 
is  practically  equally  divided  between  the  sexes,  for  example,  of 
2134  new  cases  treated  in  1915,  1094  were  males  and  1018  were 
females. 

The  age  of  the  patients  in  this  latter  group  is  of  interest  as 
bearing  on  the  question  of  prognosis:  25  per  cent,  were  between 
ten  and  twenty  years  of  age,  and  nearly  50  per  cent,  were  less  than 
thirty. 

Pathology. — Assuming  the  foot  to  have  been  normal  before  it 
began  to  break  down,  it  is  evident  that  extreme  deformity  could  not 
have  been  acquired  without  adaptive  changes  in  its  internal  struc- 
ture. In  a  general  way  these  changes  have  been  indicated  already. 
The  ligaments  on  the  internal  aspect  of  the  foot  and  of  the  ankle- 
joint  are  weak  and  distended;  the  unused  portions  of  the  articular 
surfaces  of  the  joints  may  be  denuded  of  cartilage,  while  new  facets 
may  have  formed  to  accommodate  the  changed  relations  of  the 
bones.  For  example,  the  external  malleolus  may  be  in  direct  con- 
tact with  the  OS  calcis;  evidences  of  injury  and  of  abnormal  pressure 
may  be  found  in  the  thickened  periosteum,  in  formation  of  osteo- 
phytes, while  the  internal  structure  of  the  bones  has  been  changed 
in  adaptation  to  the  new  conditions.  The  disused  muscles,  particu- 
larly the  plantar  flexors  and  adductors,  have  become  atrophied,  as 
evidenced  by  the  shrunken  calf.  The  muscles  on  the  inner  border 
of  the  foot  have  been  overstretched,  while  the  abductors  and  in  some 
instances  the  calf  muscles  have  become  shortened  and  contracted 
in  accommodation  to  the  habitual  posture.  Such  a  foot  represents 
an  extreme,  it  may  be  an  irremediable  degree  of  deformity;  but  in 
by  far  the  greater  proportion  of  the  cases  the  pathological  changes 
have  not  ad^'anced  to  a  stage  that  precludes  successful  treat- 
ment. 

Symptoms. — As  has  been  stated,  the  symptoms  of  the  weak 
foot,  although  similar  in  type,  vary  in  severity  according  to  the 
local  condition  and  the  disturbance  of  function,  the  work  to  be 


THE   WEAK  FOOT  699 

performed,  and  the  susceptibility  of  the  individuaL  The  earhest 
symptom  is  usually  a  sensation  of  weakness;  the  patient  begins  to 
recognize  as  familiar  a  feeling  of  discomfort,  of  tire  and  strain  about 
the  inner  side  of  the  foot  and  ankle;  sometimes  after  long  standing 
a  dull  ache  in  the  calf  of  the  leg  or  pain  at  the  knee,  hip,  or  in  the 
lumbar  region,  symptoms  more  common  in  women  than  in  men;  or 
after  overexertion  a  momentary  sharp  pain  radiating  from  the  point 
of  weakness;  thus  the  patient  often  dates  the  history  of  his  trouble 
from  a  long  walk  or  other  form  of  overwork.  After  a  time  the 
patient  may  become  aware  that  he  is  accommodating  his  habits 
to  his  feet;  he  rides  when  he  once  walked;  he  sits  when  he  once 
stood;  he  no  longer  runs  up  or  down  stairs  or  jumps  off  the  street- 
ear.  His  feet  have  lost  their  spring,  as  he  expresses  it,  which  means 
that  the  foot  is  no  longer  supported  and  controlled  by  muscular 
activity  and  is  no  longer  used  as  a  lever.  Not  infrequently  early 
symptoms  are  pain  and  sensitiveness  at  the  centre  of  the  heel, 
explained  in  part  by  the  jarring  heel  walk  which  is  always  assumed 
when  the  foot  is  weak,  and  in  part  by  the  strain  upon  the  attach- 
ments of  the  deep  plantar  ligaments.  The  patient  may  complain 
that  he  cannot  buy  comfortable  shoes;  the  reason  is  that  the  weak 
foot  under  use  is  changed  in  shape,  so  that  the  shoe  that  was  com- 
fortable in  the  morning  compresses  the  foot  painfully  at  night;  thus 
increasing  discomfort  from  corns,  bunions,  enlarged  great  toe- 
joints,  and  deformities  of  the  toes  is  experienced.  Coldness  and 
numbness,  congestion  and  increased  perspiration,  caused  by  the 
impaired  circulation  and  weakness,  are  common  symptoms  in  this 
class  of  cases.  Actual  pain  is,  as  a  rule,  felt  only  when  the  foot  is  in 
use;  it  ceases  under  temporary  rest  or  relief  from  disproportionate 
work,  and  it  is  this  remittance  of  symptoms,  together  with  the  fact 
that  the  discomfort  is  usually  more  marked  in  damp  weather,  that 
leads  so  often  to  the  mistaken  diagnosis  of  rheumatism. 

The  foot  is  weak  and  vulnerable;  the  patient  now  recognizes  that 
he  has  what  he  speaks  of  as  a  weak  ankle,  or  sprain,  or  gout,  or  rheu- 
matism, but  if  he  has  accommodated  himself  to  the  weakness  but 
little  discomfort  is  experienced.  In  many  instances  such  relief  or 
accommodation  is  impossible,  and  it  is  therefore  among  the  work- 
ing class  that  one  oftener  sees  rapid  development  of  the  disability 
and  deformity.  The  range  of  motion  becomes  more  and  more 
restricted;  the  habitual  attitude,  at  first  exaggerated  to  deformity 
only  under  the  influence  of  the  weight  of  the  body,  remains  as  a 
persistent  displacement.  The  weak  and  dislocated  foot  is  subjected 
to  constant  injury,  to  what  may  be  likened  to  a  succession  of  slight 
sprains,  so  that  local  congestion,  sensitiveness,  and  swelling  may 
appear,  together  with  muscular  spasm,  rigidity,  and  pain  on  passive 
motion.  Because  of  this  stiffness  of  the  foot,  which  cannot  accom- 
modate itself  to  inequalities  of  the  surface,  the  patient  dreads  to 
cross  a  rough  pavement,  for  every  misstep  causes  discomfort. 


700       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

Another  symptom,  the  discomfort  felt  m  changing  from  a  position 
of  rest  to  activity,  which  is  usually  present  in  slight  degree  at  every 
stage,  now  becomes  more  prominent.  The  patient,  after  sitting 
or  on  rising  in  the  morning,  is  unable  to  walk,  but  staggers  or  limps 
for  several  minutes,  a  symptom  explained  by  the  fact  that  when  the 
foot  is  at  rest  there  is  a  certain  relaxation  of  the  tension  that  has 
become  habitual.  The  local  sensitiveness  and  muscular  spasm  are 
increased  by  use,  so  that  the  patient  may  have  difficulty  in  removing 
the  shoe  at  night,  and  the  s\TQptoms  relieved  by  the  rest  of  Sunday 
become  progessively  worse  during  the  week.  The  pain  and  discom- 
fort are  more  general  in  character,  and  are  often  referred  to  the  dor- 
simi  of  the  foot,  representing  muscular  tension  and  contraction  and 
to  the  ankle  where  the  external  malleolus  is  grinding  out  a  facet  in 
the  projecting  os  calcis.  The  patient  may  now  complain  of  discom- 
fort in  the  feet  and  cramps  in  the  legs,  even  when  in  bed,  and  the 
weakness,  awkwardness,  and  even  mental  depression  may  be  so 
noticeable  that  the  case  is  sometimes  mistaken  for  serious  disease 
of  the  nervous  system. 

The  appearance  of  such  a  foot  has  already  been  described,  and 
the  effect  of  the  deformity  on  its  functions  should  be  evident.  The 
gait  is  slouchy,  what  has  been  spoken  of  as  the  pedestal  walk;  the 
feet  are  simply  pushed  by  one  another,  in  the  attitude  of  eversion, 
the  knees  are  slightly  flexed,  and  the  weight  is  borne  entirely  upon 
the  posterior  segment  of  the  foot.  The  muscles  have  atrophied, 
the  foot  is  cold  and  congested  from  its  continued  inactivity,  and  it 
is  usually  bathed  in  perspiration.  A  certain  range  of  motion  remains 
at  the  ankle-joint,  but  adduction  is  absolutely  restricted  by  the  short- 
ened and  spasmodically  contracted  muscles  on  the  outer  and  upper 
surface.  This  t^pe  represents,  of  course,  only  the  severe  variety 
that  is  more  likely  to  be  seen  in  hospital  than  in  private  practice; 
and  it  would  seem,  were  it  not  for  the  evidence  to  the  contrary  which 
the  histories  of  the  patients  present,  that  the  nature  of  the  trouble 
must  be  recognized  at  a  glance.  But  in  the  milder  and  earlier  cases 
the  diagnosis  is  not  always  so  easily  made. 

Diagnosis. — In  all  cases  of  suspected  weakness  of  the  foot  a 
thorough  and  orderly  examination  should  be  made,  not  only  of  its 
appearance,  but  also  of  its  functional  ability.  Such  an  examination 
is  not  merely  for  the  purpose  of  diagnosis,  but  in  order  that  the 
degree  and  character  of  the  temporary  or  permanent  changes  in 
structure  and  function  may  be  properly  estimated. 

Attitudes. — One  begins  the  examination  by  noting  the  manner  of 
standing  and  walking.  The  heel  walk,  the  exaggerated  turning 
out  of  the  feet,  the  slouchy  gait  in  which  the  leg  is  never  completely 
extended,  in  which  the  power  of  the  calf  muscle  is  not  applied,  and 
in  which  the  essential  postm-es  of  the  foot  are  disused,  are  all  ele- 
ments of  weakness  that  should  be  corrected  whether  they  cause 
symptoms  or  not. 


THE  WEAK  FOOT 


701 


Distribution  of  Weight  and  Strain. — The  distribution  of  the  weight 
of  the  body  and  the  habitual  use  of  the  foot  are  often  made  evident 
by  examining  the  worn  shoe.  If  it  is  bulged  inward  at  the  arch  or 
worn  away  on  the  inner  side  of  the  sole  it  shows  weakness  (Fig. 
542).  The  same  observations  are  then  made  on  the  bare  feet, 
particular  attention  being  paid  to  the  line  of  strain  or  leverage; 
thus  a  line  drawn  down  the  crest  of  the  tibia  from  the  centre  of  the 
patella,  continued  over  the  foot,  should  meet  the  interval  between 
the  second  and  third  toes;  if  it  falls  over  or  inside  the  great  toe,  it 
shows  that  the  foot  is  working  at  a  disadvantage  (Fig.  536). 


Fig.  538. — The  ordinary  type  of  weak  foot  in  a  child.     The  attitude  of  abduction 
causes  the  apparent  flat-foot.     (See  Fig.  539.) 

Contour.— The  contour  of  the  foot  should  then  be  examined;  its 
internal  border  should  curve  slightly  outward,  so  that  if  the  feet 
are  placed  side  by  side  with  the  toes  and  heels  in  apposition  a  slight 
interval  remains  between  them;  if  this  slight  concavity  is  replaced 
by  a  noticeable  convexity  when  weight  is  borne  the  foot  is  weak 
(Fig.  537).  This  change  in  contour  is  the  earliest  and  sometimes 
the  only  evidence  of  deformity.  The  arch  of  the  foot  properly 
protected  by  the  muscles  and  by  a  proper  attitude  sinks  but  little 
under  weight;  there  is  a  slight  elasticity  only,  as  the  strain  is  thrown 
more  to  the  inner  side  of  the  median  line,  and  if  the  depression  is 
marked  it  shows  weakness. 


702       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


Bearing  Surface. — ^The  exact  amount  of  bearing  surface  may  be 
shown  by  an  imprint  upon  carbon  paper  or  by  smearing  the  sole 
with  vasehne;  then,  as  the  patient  stands  upon  a  sheet  of  white 
paper,  the  outhne  of  the  foot  should  be  traced  so  that  the  relative 
size  of  the  imprint  to  that  of  the  foot  may  be  shown  and  compared 
with  the  normal  standard  (Fig.  544) . 

Of  all  the  tests  this,  so  often  used  to  demonstrate  the  height  of  the 
arch  and  thus  to  confirm  a  diagnosis  of  fiat-foot,  is  of  the  least 
importance. 


Fig.  539. — Voluntary    correction    of    the    deformity,    illustratinf. 
restoration  of  the  arch.     (See  Fig.  538.) 


particularly    the 


The  Range  of  Motion. — The  balance  of  the  foot,  as  shown  by  the 
range  of  motion,  is  next  to  be  tested,  for  its  limitation  is  one  of  the 
earliest  signs  of  improper  attitudes  and  of  weakness.  This  range 
of  motion  varies  somewhat  within  normal  limits ;  it  is  usually  greater 
in  childhood  than  in  adult  life,  greater  in  the  slender  than  in  the 
massive  foot,  and  greater  in  the  foot  used  properly  than  in  one  that 
is  not.  The  first  test  is  applied  to  simple  dorsal  and  plantar  flexion; 
the  leg  must  be  fully  extended  at  the  knee;  the  line  of  strain  must 
be  in  its  normal  relation,  so  that  the  foot  may  be  neither  adducted 
nor  abducted,  and  the  observation  must  be  made  on  its  outer  border. 

In  this  position  the  patient  should  be  able  to  reflex  the  foot  from 
10  to  20  degrees  less  than  the  right  angle,  and  to  extend  it  from  40 


THE   WEAK  FOOT  703 

to  50  degrees  beyond  the  right  angle,  the  range  of  motion  being 
from  50  to  60  degrees  (Figs.  516  and  517). 

By  far  the  most  important  test  is  that  of  the  power  of  adduction 
or  inversion  of  the  foot,  the  test  of  the  mediotarsal  and  subastrag- 
aloid  joints,  a  motion  in  which  the  os  calcis  is  drawn  forward  and 
inward  under  the  astragalus,  while  the  forefoot  is  flexed  about  its 
head.  With  the  leg  extended  a«id  the$"a^lla  in  the  median  line  the 
foot  is  tur,njg>^  iffif^ard  as  far  as  possible;  lJie  elevation  of  its  inner 
borderor  inversion  and  the  turning  in  of  thfe  heel  are  well  illustrated 
in  Fig.  518;  the  actual  range  of  adduction  is  somewhat  difficult  to 
measure  "but  it  is  about  30  degrees.  Even  the  mild  and  early  cases 
of  weak  foot  usually  show  some  limitation  of  this  most  important 
motion,  and  in  many  instances  it  is  completely  lost,  the  patient 
turning  the  entire  limb  in  the  effort  to  adduct  the  foot.  The  less 
important  motion  of  abduction  may  be  tested  also  (Fig.  519);  its 
range  is  about  half  that  of  adduction,  so,  also,  the  range  of  inversion 
of  the  sole  is  nearly  twice  as  great  as  that  of  e version  of  the  sole. 
In  other  words,  the  internal  border  of  the  foot  can  be  raised  twice  as 
far  from  the  floor  as  can  the  external  border.  The  range  of  passive 
motion  is  then  tested  by  pushing  the  foot  in  all  directions.  The 
range  of  dorsal  flexion  is  from  5  to  10  degrees  beyond  that  of  volun- 
tary motion,  while  passive?  extension,  so  far  as  it  applies  to  the  ankle- 
joint,  is  about  the  same  as  the  voluntary,  although  the  forefoot  may 
be  bent  downward  still  farther  at  the  mediotarsal  joint.  It  must 
be  borne  in  mind  that  dorsal  flexion,  especially  in  women,  is  a  com- 
paratively disused  attitude.  Consequently  the  inability  to  dorsi- 
flex  the  foot  beyond  a  right  angle  at  command  might  be  mistaken  for 
structural  shortening,  because  if  forced  it  causes  discomfort  in  the 
calf.  This  limitation,  however,  will  in  most  instances  disappear 
under  instruction  and  practice  and  operative  elongation  is  very 
rarely  indicated  except  in  cases  of  advanced  deformity.  The  limit 
of  passive  adduction  is  considerably  beyond  that  of  the  voluntary 
range.^ 

Passive  motion  serves  several  purposes;  contrasted  with  the 
range  of  voluntary  motion  it  shows  the  habitual  use  of  the  foot, 
since  the  motion  least  used  is  most  limited.     It  also  makes  evident 

1  As  adduction  and  inversion  and  abduction  and  eversion  are  always  combined,  one 
term  is  used  to  signify  the  movement  inward  or  outward;  thus,  inversion  means 
adduction;  abduction  implies  eversion;  strictly  speaking,  however,  adduction  and 
abduction  signify  the  relation  of  the  foot  to  the  middle  line  of  the  limb,  while  inver- 
sion and  eversion  refer  primarily  to  the  relation  of  the  sole  to  the  base.  A  fixed 
attitude  of  adduction  and  inversion  is  called  variis ;  a  fixed  attitude  of  abduction  and 
eversion  is  called  valgus.  Varus  and  valgus  signify,  therefore,  deformity.  Thus  the 
term  valgus,  although  it  may  be  properly  applied  to  designate  the  deformity  of  weak 
foot,  is  usually  reserved  for  the  more  extreme  and  persistent  distortion  of  talipes. 
The  terms  supination  and  pronation  are  sometimes  used  for  inversion  and  eversion 
and  the  terms  pronated  foot  to  designate  the  weak  or  flat-foot.  As  pronation  in  its 
general  sense  signifies  an  attitude  of  activity  it  cannot  as  correctly  describe  a  deform- 
ity which  is  essentially  one  of  inactivity  as  either  eversion  or  abduction. 


704       DISABILITIES  AXD  DEFORMITIES  OF   THE  FOOT 

the  slight  restriction  of  motion  and  the  presence  of  local  sensitive- 
ness, which,  even  in  early  cases,  are   usually  present.     Thus,  if 
pressure  is  made  just  in  front  of  and  below  the  internal  malleolus 
Ikt  the  astragalonavicular  junction,  and  if  at  the  same  time  the  foot 
|»s  forcibly  adducted,  the  patient  will  complain  of  pain  at  the  point 
|iof  pressure  and  of  a  feeling  of  constriction  and  tension  about  the 
''  dorsum  of  the  foot  before  the  normal  limit  of  motion  is  reached. 
When  the  foot  is  dorsiflexed  the  plantar  fascia  is  put  upon  the 
stretch,  and  its  condition  may  be   noted,  for  a   contracted  and 
sensitive  plantar  fascia  may  cause  sufficient  discomfort  to  induce 
improper  attitudes  and  thus  it  may  predispose  to  further  disability. 
Varieties. — This  method  of  examination  will  demonstrate  the 
disability,  and  the  secondary  changes  in  the  mechanism,  which  must 
be  overcome  before  a  cure  can  be  accomplished.     By  it  one  may 
recognize  several  grades  of  weak  foot: 

1.  The  normal  foot  improperly  used;,  as  shown  by  the  manner  of 
standing  and  walking  (Fig.  533). 

2.  The  foot  which  because  of  laxity  of  ligaments  or  insufficient 
muscular  support  is  forced  by  the  weight  of  the  body  into  an  atti- 
tude of  deformity;  that  is,  in  which  the  foot  under  weight  falls  into 
an  abnormal  attitude  of  abduction  in  its  relation  to  the  leg  as  evi- 
denced by  the  inward  projection  of  its  inner  border  and  by  the  over- 
hanging internal  malleolus.  As  a  rule  there  is  sufficient  laxity  of 
ligaments  to  permit  depression  of  the  arch,  as  shown  by  an  imprint, 
but  in  other  instances,  although  the  arch  seems  lower  because  of  the 
characteristic  attitude  of  abduction,  in  which  the  leg,  as  it  were, 
overhangs  the  foot,  yet  the  imprint  shows  that  there  is  no  increase 
in  the  area  of  bearing  siu-face.  Indeed,  if  the  eversiou  is  sufficient 
to  raise  the  outer  border  of  the  foot,  this  may  be  even  smaller  than 
normal;  thus  an  individual  may  be  disabled  by  so-called  flat-foot 
whose  arch  is  actually  exaggerated  (Fig.  537). 

3.  The  weak  foot,  which  shows  typical  deformity  under  use  and  in 
which  the  range  of  voluntary  motion  is  somewhat  limited,  particu- 
larly in  the  direction  of  plantar  flexion  and  adduction.  Forced 
motion  causes  discomfort  and  pain,  indicating  certain  accommo- 
dative changes  in  structure,  which  are  not  apparent  when  the  foot 
is  not  in  use  (Fig.  538). 

4.  The  foot  which  presents  t^-pical  and  persistent  deformity, 
whether  it  is  in  use  or  not,  and  in  which  the  range  of  both  \-oluntary 
and  passive  motion  is  much  restricted.  In  all  of  these  varieties  the 
improper  functional  use  of  the  foot,  particularly  the  loss  of  active 
leverage,  is  xery  evident  when  the  patient  walks  (Fig.  542). 

Limitation  of  Motion  and  Muscular  Spasm. — Limitation  of  motion 
is  caused  by  the  changes  in  structure  in  accommodation  to  functional 
use.  These  are  first  evident  in  the  muscles,  then  in  the  ligaments, 
and,  finally,  in  the  articular  surfaces  of  the  bones.  Added  to  this 
underlying  limitation  of  motion  there  is  usually  a  certain  degree  of 


THE  WEAK  FOOT  705 

muscular  spasm,  which  varies  in  grade  with  the  local  congestion, 
irritation,  and  inflammation  of  the  joints  and  tissues.  In  the  quies- 
cent flat-foot  it  may  be  absent,  but  on  renewed  injury  or  overwork 
of  the  weak  structure  it  again  appears.  It  depends  also  upon  the 
irritable  condition  of  the  overworked  and  contracted  abductor 
muscles,  practically  the  only  group  which  retains  functional  power; 
thus  the  spasm,  as  has  been  stated  in  describing  the  severe  and  pain- 
ful type  of  weak  foot,  is  greater  after  the  day's  use  and  relaxes  some- 
what during  the  night.  The  degree  of  muscular  spasm  and  rigidity 
correspoiids  with  the  intensity  of  the  symptoms,  but  by  no  means 
with  the  depression  of  the  arch  or  with  the  duration  of  the  deformity. 

Extreme  Types  of  Weak  Foot. — 1.  Persistent  Abduction, — In  one 
type  of  deformity  the  foot  is  twisted  outward  and  upward.  It  may 
be  everted  to  such  an  extent  that  practically  the  weight  is  borne 
upon  the  heel  and  the  ball  of  the  great  toe.  The  entire  foot  is 
simply  held  in  an  attitude  of  extreme  abduction  and  dorsal  flexion 
by  the  spasm  and  contraction  of  the  flexors  and  abductors,  so  that 
the  leg  must  be  bent  at  the  knee  and  inclined  forward  to  bring  the 
sole  to  the  ground.  Such  extreme  cases  are  uncommon.  They  are 
often  the  direct  result  of  injury,  so-called  chronic  sprain.  Less 
extreme  examples  of  this  class  are  very  common.  The  foot  is  simply 
turned  to  one  side  (valgus)  and  the  arch  appears  to  be  depressed 
because  of  the  attitude,  whereas  it  may  be  in  reality  exaggerated 
in  depth. 

2.  Pes  Planus.; — As  has  been  stated  already,  and  as  is  well-known, 
there  is  a  type  of  true  painless  flat-foot  sometimes  called  pes  planus, 
in  which  the  flatness  of  the  foot  is  more  noticeable  than  the  other 
components  of  the  deformity  that  have  been  described.  This  is 
probably  the  result  of  inherited  laxity  of  ligaments  or  of  rhachitis 
or  other  form  of  acquired  weakness  in  early  life,  so  that  a  normal 
arch  was  never  present.  Such  a  foot  controlled  by  normal  muscles 
may  be  strong  and  efficient,  but  it  is,  nevertheless,  deformed,  and 
it  is  doubtful  if  its  possessor  ever  could  attain  the  grace  and  elas- 
ticity of  gait  possible  under  normal  conditions.  It  is  said,  also, 
that  a  low  arch  is  normal  in  certain  races,  for  example,  the  negro, 
but  the  American  negro  is  certainly  not  exempt  from  the  pain  and 
disability  incidental  to  the  broken-down  foot. 

It  is  evident,  of  course,  that  the  breaking  down  of  a  properly 
shaped  foot,  supported  by  normal  ligaments,  will  be  attended  by 
greater  pain  and  greater  disability  than  of  one  in  which  the  arch 
was  originally  low  and  of  which  the  ligaments  were  weak,  because 
it  is  during  the  progression  of  the  deformity  and  particularly  in  its 
early  stages  that  such  symptoms  are  most  prominent.  When  the 
bones  of  the  arch  rest  upon  the  ground  or  when  final  stability  has 
become  assured,  pain  may  cease,  and  permanent  accommodation 
to  the  new  conditions  may  increase  the  ability  of  the  deformed 
member.  Such  an  outcome  might  be  quickly  accomplished  in  the 
45 


706       DISABILITIES  ASD  DEFORMITIES  OF   THE  FOOT 

foot  orijjinally  flat,  while  in  the  other  instance  the  symptoms, 
although  remitting  from  time  to  time,  might  continue  indefinitely. 
The  abducted  foot,  in  which  there  is  no  depression  of  the  arch, 
and  the  simple  flat-foot,  in  which  the  element  of  abduction  is  less 
])rominent,  represent  the  two  extremes  of  weak  foot.  In  the  major- 
ity of  cases  the  two  are  combined  in  varying  degree. 


Fig.  540. — "Weak  feet  and  slight  knock-knees. 


One  may  recognize,  then,  tlu'ee  t^■pes  of  weak  foot  which  may  be 
classified  according  to  the  more  noticeable  deformity  as 

1.  Valgus,  or  abduction.  ^ 

2.  Valgoplanus,  or  abduction  and  depression. 

3.  Planovalgus,  or  depression  and  abduction. 

This  distinction  is  of  some  importance  from  the  stand-point  of 
prognosis,  at  least  in  the  adolescent  and  adult  cases,  as  the  pros- 
pect of  anatomical  ciu-e  corresponds  to  the  order  of  classification. 

Weak  Foot  in  Childhood. — There  can  be  no  doubt  that  in  many 
instances  the  origin  of  the  weak  foot  may  be  traced  to  early  child- 
hood. Certainly,  deformities  and  improper  attitudes  are  very 
common  at  this  period,  and  it  is  much  more  likely  that  they  are 
ingroT^ii  than  outgrown.  Actual  pain  from  the  weak  foot  is  unusual 
at  this  age.  The  child  may  complain  of  fatigue  and  may  be  weak 
and  awkward,  but  it  is  usually  because  of  the  very  evident  deformity 
rather  than  because  of  s\Tnptoms  that  advice  is  askedr  In  these 
cases,  as  in  every  case,  the  habitual  attitudes  and  use  of  the  feet  are 
of  the  first  importance. 


THE   WEAK  FOOT  707 

Out-toeing  and  In-toeing  as  Symptoms. — One  of  the  most  common 
of  the  improper  postures  of  civiUzation  is  that  of  exaggerated  out- 
outward  rotation  of  the  hmbs  (turning  outward  of  the  feet),  which 
is  not  only  an  ungraceful  attitude,  but  a  direct  cause  of  weakness 
as  well.  The  opposite  attitude  of  inward  rotation,  the  so-called 
"pigeon-toed"  walk,  is  most  offensive  to  relatives  and  friends,  and 
it  is  for  correction  of  the  attitude  that  the  child  may  be  brought  for 
treatment.  The  attitude  is,  in  many  instances,  a  sign  of  the  weak 
foot,  for  on  examination  the  bulging  on  the  inner  side,  the  inward 
rotation'of  the  leg  in  its  relation  to  the  foot,  and  the  depressed  arch 
show  very  plainly  that  it  is  the  foot  and  not  the  attitude  that  requires 
treatment;  in  fact,  the  attitude  is,  in  this  class  of  cases,  really  a  safe- 
guard against  increasing  deformity,  which  will  correct  itself  when 
its  cause  is  removed.^  Particular  emphasis  is  laid  upon  this  point, 
which  is  very  generally  overlooked,  because  the  routine  treatment 
of  the  "pigeon-toes"  in  these  cases  might  be  the  cause  of  direct 
harm. 

Weak  Ankles. — "Weak  ankle"  is  a  term  popularly  applied  to  the 
weak  foot  of  childhood,  in  which  the  foot  is  in  a  position  of  valgus 
when  in  use,  so  that  the  sole  of  the  shoe  is  worn  away  on  its  inner 
side.  Weak  ankles  are  very  common  in  young  children  and  are 
often  one  of  the  results  of  general  weakness  due  to  defective  assimi- 
lation. At  this  age  the  foot  is,  in  addition,  usually  flat  (Fig.  540), 
but  in  the  valgus  or  weak  ankle  of  later  years  the  arch  is  often  found 
to  be  exaggerated  when  the  foot  is  placed  in  proper  relation  to  the 

Outgrown  Joints. — In  older  children  "outgrown"  joints  often 
attract  the  mother's  attention;  the  internal  malleoli  appear  promi- 
nent because  of  the  position  of  valgus,  or  because  of  the  turning 
out  of  the  feet  the  malleoli  may  strike  against  one  another,  "  inter- 
fere," and  thus  there  may  be  an  actual  hypertrophy  of  the  tissues 
over  the  projecting  bones  from  local  irritation. 

Another  type  is  the  long,  slender  abducted  foot,  in  which  the 
inward  bulging  at  the  mediotarsal  joint  is  indicated  by  the  point  of 
wear  in  the  leather  of  the  shoe  (Fig.  537). 

In  the  weak  foot  of  childhood,  although  restriction  of  voluntary 
and  passive  motion  may  be  present,  there  are,  as  a  rule,  but  little 
local  sensitiveness  and  muscular  spasm,  and,  as  has  been  said,  but 
little  actual  pain,  for  the  reason  that  the  weak  foot  in  childhood  is 
not  subjected  to  the  strain  of  constant  occupation  or  to  the  burden 
of  an  overweighted  body.  There  is  also  another  important  differ- 
ence: the  foot  of  the  adult  is  obliged  to  bear  greater  strain  than 
any  other  part,  and  although  normal  in  structure  it  may  be  over- 
worked, so  that  in  many  instances  the  weakness  of  the  foot  is  the 

1  Inward  rotation  of  the  limb,  an  attitude  controlled  by  the  muscles  at  the  hip, 
and  inversion  of  the  foot  are  usually  confounded.  Inward  rotation  of  the  limb 
(pigeon-toe)  and  eversion  of  the  foot  (weak  foot)  are  often  combined  in  childhood. 


708       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

only  disability.  But  in  childhood,  when  such  exciting  causes  are 
absent,  a  weak  foot  is  very  often  a  local  indication  of  general  weak- 
ness and  loss  of  tone. 

Irregular  Forms  of  Weak  Feet. — Occasionally  the  apex  of  the  inward 
bulging  and  deformity  is  not  at  the  mediotarsal  joint,  but  anterior 
to  it  in  the  cuneiform  region.  In  such  cases  the  internal  cuneiform 
bone  may  be  enlarged  and  sensitive  to  pressure. 

Another  form  is  the  combination  of  a  plantar  flexed  toe  with  a 
depressed  arch  (Fig.  543).  Extreme  deformity  of  this  class  is 
usually  congenital.  A  milder  t}^e  is  not  uncommon.  (See  Hallux 
Rigidus.)  A  third  variety  is  eversion  at  the  mediotarsal  region 
combined  with  marked  adduction  of  the  metatarsus.  This  is  a 
congenital  deformity. 


Fig.  541. — Congenital  flat-foot. 
Rigid  deformity  of  an  extreme 
type,  illustrating  the  component 
abduction  and  obliteration  of  the 
arch. 


Fig.  542. — Flat-foot,  illustrating  exti'eme 
deformitj'  in  childhood. 


Weak  Feet  and  Deformity  of  the  Legs. — In  childhood  weak  feet 
are  often  seen  in  combination  with  slight  knock-knees  (Fig.  540), 
while  in  later  life  knock-knee  usually  induces  in  compensation  the 
opposite  attitude  of  adduction.  (See  Knock-knee.)  Bow-leg  in 
childhood  is  usually  accompanied  by  slight  adduction  of  the  feet, 
but  later  there  is  usually  a  certain  degree  of  compensatory  valgus, 
although  it  does  not,  as  a  rule,  cause  discomfort. 

General  Weakness. — The  direct  effects  of  the  weak  and  painful 
foot  have  been  described  in  detail.  It  must  be  borne  in  mind  that 
the  feet  support  the  body,  and  that  an  insecure  support  affects  the 
entire  mechanism.     General  functional  weakness  and  awkwardness, 


The  weak  foot 


709 


the  flat  chest,  round  shoulders,  or  other  curvatures  of  the  spme,  are 
often  observed  as  accompaniments  or  effects  of  weak  feet.  Thus, 
as  a  rule,  the  systematic  treatment  of  any  form  of  postural  weakness 
must  include  the  treatment  of  the  feet  as  well. 

Review. — The  disability  and  deformity  of  the  weak  or  so-called 
■flat-foot  are  caused  by  disproportion  between  the  strength  of  the 
foot  and  the  weight  and  strain  to  which  it  is  subjected. 

The  foot  may  be  weakened  by  injury  or  disease;,  it  may  be  over- 
burdened by  the  body  weighty  or  overstrained  by  laborious  occu- 
pation,,or  the  broken-down  foot  may  be  simply  one  indication  of 
general  bodily  weakness.  It  is  unnecessary  to  enumerate  all  the 
various  factors  that  singly  or  combined  lead  to  this  disability.  It 
may  be  stated,  however,  that  in  adult  life  the  weak  foot  is  in  many 
or  most  instances  the  only  disability  that  demands  treatment.     Its 


Fig.  o-i.'j. — Hamiuer-toe  flat-foot. 


most  constant  predisposing  causes  are  the  direct  injury  caused  by 
improper  shoes  and  the  mechanical  disadvantages  to  which  it  is 
subjected  by  the  assumption  of  improper  attitudes. 

All  weak  or  flat  feet  are  mechanically  weak,  but  all  weak  feet  are 
by  no  means  painful  feet.  Pain,  the  symptom  of  overstrain  or 
injury,  bears  no  definite  relation  to  the  degree  of  deformity. 

In  certain  instances  persistent  abduction  of  the  foot  may  be 
accompanied  by  exaggeration  of  the  arch;  in  others,  the  flattening 
of  the  arch  may  be  the  most  noticeable  deformity,  but  in  most  cases 
the  two  are  combined  in  varying  degree.  And  as  each  deformity 
is  an  evidence  of  weakness,  it  seems  hardly  necessary  to  make  a 
radical  distinction  between  the  two,  except  as  regards  prognosis. 
For  the  abducted  foot  in  which  the  arch  is  intact  is  almost  always 
an  acquired  deformity  of  short  duration,  whereas  in  the  case  of  the 


710       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

foot  in  which  the  arch  is  obhterated  the  deformity  usually  dates 
from  early  childhood,  and  it  is  therefore  less  amenable  to  treatment 
as  far  as  perfect  cure  is  concerned. 

Treatment. — The  principles  of  the  treatment  which  leads  to  the 
permanent  cure  of  the  weak  and  deformed  foot  are  very  simple, 
but  the  application  varies  somewhat  according  to  the  grade  and 
duration  of  the  deformity.  The  object  of  treatment  is  to  so  change 
the  weak  foot  that  it  may  conform  not  only  in  contour  but  in  habit- 
ual attitudes  and  in  power  of  voluntary  motion  to  the  normal  foot, 
because  complete  cure  is  impossible  unless  normal  function  is 
regained.  The  first  step  must  be,  therefore,  to  make  passive  motion 
free  and  painless  to  the  normal  limit.  In  other  words,  the  obstruc- 
tions to  the  motion  of  the  mechanism  must  be  removed  before  the 
power  can  be  properly  applied ;  for  the  increase  of  muscular  strength 
and  ability,  on  which  ultimate  cure  depends,  is  not  possible  while 
motion  is  restrained  by  deformity  or  by  pain  or  by  adhesions  or 
contractions. 

The  weak  foot,  because  of  inefficient  ligaments  and  muscles  unable 
to  hold  itself  in  proper  position,  must  be  supported  until  regenera- 
tive changes  have  taken  place  in  its  structure.  Such  support  is 
necessary  to  retain  the  joints  in  normal  position,  and  to  hold  the 
weight  in  proper  relation  to  the  foot,  otherwise  normal  function  is 
impossible.  When  these  essentials  are  provided  the  patient  may 
cure  himself  by  the  proper  functional  use  of  the  foot  and  by  the 
avoidance  of  attitudes  that  place  it  at  a  disadvantage. 

It  may  be  well  to  describe,  first,  the  treatment  that  must  be 
applied  to  all  classes  of  weak  foot  in  which  a  cure  is  to  be  attempted 
and  which  by  itself  is  sufficient  in  the  milder  types,  before  calling 
attention  to  the  modifications  that  may  be  necessary  in  more 
advanced  cases. 

The  Shoe. — In  all  cases  it  will  be  necessary  to  provide  the  patient 
with  a  proper  shoe,  for  the  shoe  is  usually  the  direct  cause  of  the 
minor  deformities,  and  indirectly,  in  many  instances,  of  more  serious 
disability.  Indeed,  most  of  the  deformities  and  disabilities  of  the 
foot  are  incidental  to  civilization,  and  are  therefore  confined  to  the 
shoe- wearing  people.  The  direct  effect  of  the  ordinary  shoe  is  to 
lessen  the  area  and  the  adjustability  of  the  fulcrum  by  cramping 
the  toes.  Indirectly  it  causes  deformities — corns,  bunions,  and 
the  like — which  serve  to  make  active  movement  or  leverage  painful, 
so  that  it  is  replaced  by  the  passive  attitude. 

The  proper  shoe  should  contain  sufficient  space  for  the  independ- 
ent movements  of  the  toes.  This  motion  is  illustrated  in  the  walk 
of  the  barefoot  child.  As  the  weight  falls  on  the  foot  the  toes  spread, 
and  as  the  body  is  raised  on  the  foot  they  contract.  The  important 
leverage  action  of  the  great  toe  and  support  afforded  by  it  to  the 
arch  of  the  foot  have  been  mentioned  already.  The  shape  of  the 
sole  should  correspond  to  the  shape  of  the  foot  and  the  heel  should 


THE   WEAK  FOOT 


711 


be  broad  and  low.  It  will  be  noted  that  the  front  of  the  sole  of  the 
shoe  in  Fig.  544  appears  to  be  twisted  inward.  Such  a  shoe  aids  in 
preventing  abduction,  and  it  is  therefore  an  important  adjunct  to 
the  brace  in  restraining  deformity. 

Raising  the  Inner  Border  of  the  Shoe.—  A  simple  expedient  in  the 
treatment  of  the  weak  foot  and  an  aid  in  balancing  it  properly  is  to 
make  the  inner  border  of  the  sole  and  heel  of  the  shoe  slightly 
thicker  in  order  to  throw  the  weight 
toward    the   outer    side    of    the    foot. 
This   is^of  special   importance   in  the 
treatment  of  the   slighter   degrees   of 
what  is  known  as  weak  ankle,  and  it  is 
always  of  ser^dce  in  the  treatment  of 
any  grade  of  weak  foot. 

Attitudes. — The  patient's  attention 
is  then  called  to  the  significance  of 
the  bulging  on  the  inner  side  of  the  foot 
(Fig.  538)  and  how  this  may  be  pre- 
vented by  throwing  the  weight  on  the 
outer  side  of  the  foot  (Fig.  539)  and  by 
holding  the  feet  parallel  with  one 
another  in  standing  and  by  crossing 
the  feet  in  the  sitting  posture  and  by 
the  assumption  of  the  proper  attitude 
in  walking  (Fig  514).  The  importance 
of  leverage  is  shown  him,  that  he  must 
try  to  press  down  the  sole  of  the  shoe 
with  his  toes,  particularly  with  the 
great  toe,  and  employ  the  active  lift 
of  the  calf  muscles  b}^  fully  extending 
the  leg  and  raising  the  body  on  the  foot 
from  time  to  time  (Fig.  514).  Finally, 
in  standing,  he  must  avoid  long  con- 
tinuance in  one  position,  especially  the 
passive  posture,  which,  even  in  the 
normal  subject,  simulates  the  attitude 
and  deformity  of  weak  foot.  In  short, 
he  must  be  instructed  in  the  mechanics 
of  the  foot  and  taught  how  the  weak  foot 
maybe  protected  as  well  as  strengthened. 

Exercises. — It  is  important,  also,  to  demonstrate  to  the  patient 
the  normal  range  of  motion  of  the  foot,  motion  which,  if  restricted, 
must  be  regained  by  voluntary  and  passive  exercises.  Voluntary 
exercise  should  be  devoted  to  strengthening  the  adductors  and  plan- 
tar flexors;  thus  the  foot  should  be  adducted  and  inverted,  then 
dorsiflexed  in  the  attitude  of  slight  adduction  (Fig.  518)  over  and 
over  again  at  every  opportunity.     Tip-toe  exercises  are  expecially 


Fig.  544. — The  proper  rela- 
tion of  the  sole  to  the  shape 
of  the  foot:  A,  outline  of  sole; 
B,  outline  of  foot;  C,  imprint  of 
foot. 


712       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

useful;  the  patient,  placing  the  feet  in  the  attitude  of  moderate 
inward  rotation,  raises  the  body  on  the  toes  to  the  extreme  limit,  the 
limbs  being  fully  extended  at  the  knees,  then  sinking  slowly,  resting 
the  weight  on  the  outer  borders  of  the  feet,  in  the  attitude  of  marked 
varus,  twenty  to  one  hundred  times.  This  exercise  is  somewhat 
difficult,  and  "it  cannot  be  carried  out  properly  if  there  is  any  hmita- 
tion  of  motion  o  rsensitiveness  at  the  mediotarsal  joints.  The  best 
of  all  exercises  is,  however,  the  proper  walk,  in  which  the  leverage 


Fig.  545. — The  tip-toe  exercise,  raising 
the  body  on  the  adducted  feet.  (See  Fig. 
546.) 


Fig.  546. — The  tip-toe  exercise, 
resting  on  the  outer  borders  of  the 
feet.     (See  Fig.  545.) 


power  of  the  foot  is  employed  and  in  which  it  passes  through  the 
proper  alternation  of  postures  (Fig.  514).  Treatment  by  massage 
and  special  g^Tnnastic  exercises  is,  of  coiu-se,  of  benefit  if  the  patient 
can  command  it,  although  by  no  means  essential  to  the  cure. 

Support. — In  many  instances  the  simple  treatment  that  has  been 
outlined  is  all  that  is  required,  but  in  the  majority  of  cases  the  patient 
is  not  able  to  prevent  deformity  voluntarily;  consequently  a  sup- 
port is  necessary  to  hold  the  foot  in  proper  position  and  to  relieve 
discomfort.     It  is  usually  necessary  in  the  treatment  of  the  weak 


THE  WEAK  FOOT  713 

foot  of  childhood  because  one  cannot  command  the  aid  of  the 
patient. 

In  selecting  a  support  for  the  weak  foot  the  nature  of  the  deformity 
should  be  borne  in  mind;  that  the  acquired  flat-foot,  for  example, 
is  not  a  direct  breaking  down  of  the  arch,  as  is  usually  taught,  but  a 
lateral  deviation  and  sinking — a  compound  deformity,  as  has  been 
already  described  (Fig.  533).  Thus  a  brace  to  be  efficient  must  hold 
the  foot  laterally  as  well  as  support  the  arch.  But  it  must  not 
prevent  the  normal  motions  of  the  foot,  and  thus  interfere  with  the 
increase  .of  muscular  strength  and  ability,  on  which  ultimate  cure 
depends. 

The  supports  that  are  ordinarily  used  for  flat-foot  do  not  fulfil  the 
conditions;  the  pads,  springs,  and  plates  placed  beneath  the  arch 
are  intended  to  support  it  by  direct  pressure  without  regard  to  the 
abduction;  they  are  usually  ill-fitting,  and  are  often  of  such  length 
and  shape  as  to  splint  the  foot  and  thus  to  restrict  its  motion.  Leg 
braces  which  control  the  valgus  do  not  often  hold  the  foot  accurately, 
and  their  weight  and  unsightliness  are  fatal  objections  to  their  use, 
especially  in  the  early  cases,  in  which  prevention  of  subsequent 
deformity  is  of  such  importance. 

A  brace  should  never  be  applied  to  a  deformed  and  rigid  foot 
because  it  cannot  adapt  itself  to  the  support;  the  spasm  and  rigidity 
should  be  first  relieved  by  the  preliminary  treatment  which  will  be 
described  in  the  consideration  of  this  class  of  cases. 

The  Construction  of  the  Brace. — ^To  properly  construct  a  brace  to 
meet  these  conditions  it  is  necessary  to  provide  the  machanic  with 
a  plaster  cast  of  the  foot,  taken  in  the  attitude  in  which  one  wishes 
to  support  it.  Such  a  model  may  be  easily  and  quickly  made  in  the 
following  manner: 

The  Plaster  Cast. — Seat  the  patient  in  a  chair;  in  front  of  him 
place  another,  preferably  a  rocking  chair,  somewhat  less  in  height; 
on  it  lay  a  thick  pad  of  cotton-batting  and  cover  it  with  a  square  of 
cotton  cloth.  Put  about  a  quart  of  cold  water  into  a  basin  and 
sprinkle  plaster-of-Paris  on  the  surface  until  it  does  not  readily 
sink  to  the  bottom;  then  stir.  When  the  mixture  is  of  the  consist- 
ency of  very  thick  cream  pour  it  upon  the  cloth.  The  patient's 
knee  is  then  flexed,  and  the  outer  side  of  the  foot,  previously  rubbed 
mth  talcum  powder,  is  allowed  to  sink  into  the  plaster,  and,  the 
borders  of  the  cloth  being  raised,  the  plaster  is  pressed  against  the 
foot  until  rather  more  than  half  is  covered.  The  foot  should  be 
placed  toward  the  higher  side  of  the  chair  seat,  the  object  of  the 
inclined  plane  and  the  lower  surface  being  to  utilize  the  force  of 
gravity  to  hold  the  foot  in  slight  adduction.  The  foot  should  be  at 
an  angle  with  the  leg,  corresponding  to  its  usual  position  in  the  shoe, 
that  is,  slightly  plantar  flexed,  and  the  sole  should  be  in  the  plane 
perpendicular  to  the  seat  of  the  chair;  the  toes  need  not  be  included 
(Fig.  549) .     As  soon  as  the  plaster  is  hard  its  upper  surface  is  coated 


714       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


1 

i 

"^  'iBlk 

s 

^» 

Fig.  547. — The  attitude  in  which  the  plaster  cast  should  be  taken.  This  attitude 
in  which  the  weight  rests  upon  the  outer  border  is  important,  because  in  it  the  foot 
assumes  the  best  possible  contour.  If  the  sole  is  simply  pressed  downward  into  the 
plaster  cream,  the  ordinary"  method  of  making  the  model,  the  shape  will  be  found 
to  be  quite  different  from  that  taken  in  the  manner  illustrated. 


Fig.  54S. — A  cast  marked  for  the  mechanic.  In  most  instances  the  internal  flange 
is  made  as  in  this  illustration,  as  compared  with  Fig.  552,  in  order  to  strengthen  the 
support  so  that  light  steel  (gauge  20)  may  be  used.     (See  Fig.  552.) 


-The  lower  half  of  the  plaster 
mould. 


Fig.  550. — The    plaster    mould    com- 
pleted. 


THE   WEAK  FOOT 


715 


with  vaseline  or  talcum  powder  and  the  remainder  of  the  foot  is 
covered  with  plaster;  the  two  halves  are  then  removed,  dusted  with 
talcum  powder,  bound  together,  and  filled  with  the  plaster  cream. 
In  a  few  moments  the  outer  shell  may  be  removed,  and  one  has  a 
reproduction  of  the  foot,  which,  when 
properly  made,  should  stand  upright 
without  inclination  to  one  side  or  the 
other  (Fig.  548). 

In  most  instances  it  will  be  of  ad- 
vantage* to  deepen  in  the  plaster 
model  the  inner  and  outer  segments 
of  the  arch,  in  order  that  the  arch  of 
the  brace  may  be  slightly  exaggerated, 
especially  at  the  heel,  so  that  the  de- 
pression of  the  anterior  extremity  of 
the  OS  calcis  may  be  prevented.  If 
the  outer  border  of  the  cast  is  flattened 
by  pressure  a  little  plaster  should  be 
added  to  approximate  its  normal 
rounded  contour. 

The  Brace. — Upon  the  model  the 
outline  of  the  brace  is  drawn  as  illus- 
trated in  the  diagrams.  The  best 
sheet  steel,  18-  to  20-gauge,  cut  after 

the  pattern  is  moulded  upon  it  and  tempered,  so  that  as  it  is 
applied  for  the  purpose  of  preventing  deformity,  it  may  be  prac- 
tically unyielding  to  the  weight  of  the  body. 


Fig.  551. — The  outline  of  the  sole 
part  of  the  brace. 


Fig.  552. — A,  the  astragalonavicular  joint.  The  internal  flange  of  the  brace  should 
rise  well  above  all  the  prominent  bones  to  a  point  about  half  an  inch  below  the 
malleolus. 


It  will  be  noticed  that  the  brace  clasps  the  weak  part  of  the  foot 
and  holds  it  together;  the  broad  internal  upright  portion  (Fig. 
551)  covers  and  protects  the  astragalonavicular  junction,  rising 
well  above  the  navicular;  the  external  arm  covers  the  calcaneo- 
cuboid junction  and  the  outer  aspect  of  the  foot  to  a  height  sufficient 


716       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


to  hold  the  foot  securely  (Fig.  551).  The  sole  part  provides  a  firm, 
comfortable  support,  yet,  reaching  only  from  the  centre  of  the  heel 
to  just  behind  the  ball  of  the  great  toe,  it  does  not  restrain  the  normal 
motions  of  the  foot  (Fig.  bb-^).  The  brace  may  be  nickel-plated 
which  makes  a  smooth  finish,  or  galvanized,  which  makes  a  more 
diuable  covering.  It  may  be  covered  with  leather,  or  an  inner  sole 
may  be  placed  on  its  upper  surface;  but  this  is  not  usually  necessary. 
As  it  is  fitted  to  the  foot,  it  finds  and  holds  its  own  place  in  the  shoe, 
so  that  no  attaclunent  is  required;  thus  it  may  be  changed  from  one 
shoe  to  another.  Xot  only  does  it  hold  the  foot  laterally  and  from 
beneath,  but  there  is  an  element  of  suggestiveness  in  the  slight 
leverage  action  which  is  very  important,  and  which  is  a  distinctive 
feature  of  this  brace  as  contrasted  with 
simple  sole  plates  or  other  supports. 

The  Positive  Action  of  a  Proper  Brace. 
— The  patient,  instructed  to  throw  his 
weight  upon  the  outer  side  of  the|foot 
and  wearing  the  shoe  which  has|been 
tilted  in  the  same  direction  by  thicken- 
ing the  inner  border  of  the  sole  and  heel, 


Fig.  553. — B,  the  calcaneocuboid  junction.  The 
external  flange  extends  from  the  centre  of  the  heel  to 
a  point  just  beliind  the  base  of  the  fifth  metatarsal 
bone. 


Fig.  ■  554. — C,  the  great 
toe-joint;  D,  the  centre  of 
the  heel. 


presses  down  the  external  arm  and  thus  lifts  the  internal  flange 
against  the  inner  side  of  the  foot,  which  is  instincti^•ely  drawn  away 
from  the  pressure  and  thus  toward  the  normal  contom.  lie  no 
longer  turns  the  feet  outward  in  walking,  because  this  causes  posi- 
tive discomfort,  and  he  is  not  likely  to  assimie  the  passive  attitude 
because  of  the  suggestive  lateral  pressiue  of  the  support.  With  the 
foot  held  in  the  normal  attitude  the  patient  may  again  walk  with 
the  proper  spring;  thus  the  brace  itself  becomes  a  "positiv?  aid  in 
the  physiological  cure  as  contrasted  Avith  sole-plates  and  stiftened 
shoes.  It  is  important,  also,  that  a  shoe  of  proper  shape,  as  shown 
in  the  diagram  (Fig.  544),  be  worn,  as  it  aids  the  brace  in  holding 
the  foot  in  an  attitude  of  slight  adduction. 

The  shape  of  the  brace,  in  general  like  that  of  the  diagram,  is 


THE  WEAK  FOOT  717 

modified  in  certain  cases;  for  instance,  the  entire  internal  aspect 
of  the  foot  may  be  weak  and  must  be  covered  by  the  internal  flange. 
In  very  heavy  subjects  the  sole  portion  must  be  made  larger, 
although  this  is  a  disadvantage,  as  it  lessens  the  leverage  action; 
other  slight  modifications  may  be  necessary  in  special  cases.  If 
any  portion  of  the  rim  of  the  brace  causes  discomfort,  the  edge 
may  be  turned  away  slightly  at  the  point  of  pressure  by  a  wrench. 
After  a  few  days  the  patient  no  longer  notices  the  constraint  of  the 
brace,  and  as  its  presence  in  the  shoe  is  not  evident,  it  may  be  worn 
indefinitely.  Steel  is  the  lightest  and  strongest,  and,  on  the  whole, 
the  most  satisfactory  material  for  the  brace.  It  is,  of  course, 
liable  to  rust,  and  for  this  reason  each  patient  may  be  provided 
with  two  pairs  of  braces,  in  order  that  the  rusted  pair  may  be 
returned  to  the  brace-maker  for  repairs.  In  hospital  practice  heavier 
material  is  used  and  the  braces  are  galvanized,  which  is  fairly 
resistant.^ 


Fig.  555. — The  combination  foot  brace,  providing  support  for  the  metatarsal  as  well 
as  the  longitudinal  arch. 

Support  is  usually  necessary  for  from  three  months  to  a  year 
or  longer,  according  to  the  condition  of  the  patient  and  the  strain 
to  which  the  feet  are  subjected.  The  brace,  accurately  made  and 
adjusted  under  suitable  conditions,  causes  no  more  pressure  or 
discomfort  than  a  well-made  shoe,  for  its  principle  is  quite  different 
from  that  of  the  ordinary  supports  that  are  in  common  use,  to 
which  this  objection  has  been  made.  This  brace  supports  the  arch 
primarily  by  preventing  abduction,  consequently  its  pressure  is 
first  felt  upon  the  lateral  aspect  of  the  foot,  a  pressure  that  the 
patient  can  relieve  by  improving  his  attitude.  The  brace  should 
afford  support  when  necessary,  and  at  all  times  suggest  and  enforce 
a  proper  attitude;  it  is,  however,  but  one  of  the  essential  factors 
in  the  general  scheme  of  treatment.  The  ordinary  form  of  brace 
in  all  its  modifications  conforms  to  the  shape  of  an  inner  sole  (Fig. 
556).  As  it  supports  the  sole  of  the  foot,  and  by  the  elevation  of 
its  inner  border  tends  to  throw  the  weight  more  toward  the  outer 

1  In  many  instances  there  is  a  rapid  improvement  in  the  shape  of  the  foot  under 
treatment,  and  it  is  often  advisable  to  make  a  second  cast  within  a  few  months,  in 
order  that  the  brace  may  conforna  to  the  improved  contour. 


718       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

side,  it  is  a  useful  aid  in  treatment;  but,  providing  no  lateral  support, 
it  cannot  pre\-ent  the  imvard  bulging  of  the  foot,  which  is  the  most 
important  element  of  the  deformity,  and  as  compared  to  a  positive 
brace  which  prevents  its  primary  deformity  it  is  therefore  an 
ineffective  apparatus. 

In  the  treatment  of  children  the  foot  should  be  moved  in-  all 
directions,  but  particularly  in  dorsal  flexion  and  adduction  to 
the  full  limit  at  morning  and  at  night,  until  the  child  has  regained 
the  normal  muscular  power  and  ability.  Special  gymnastics  and 
massage  are  always  desirable,  and  they  may  be  necessary  in  certain 
cases.  Bicycling  may  be  cited  as  one  of  the  best,  and  roller-skating 
as  one  of  the  worst  exercises  for  the  weak  foot.  A  year  is  about 
the  time  required  for  a  cure  of  the  weak  foot  in  childhood,  although 
attention  to  the  shoes  and  to  the  attitudes  must  be  continued 
indefiniteh'. 


Fig.  556. — The  typical  sole  plate  ordinarily  used  in  the  treatment  of  weak    foot. 
(After  Bradford  and  Lovett.) 


THE    RIGID   WEAK   FOOT. 

One  may  now  contrast  with  the  mild  types  of  weakness  that 
have  been  described  the  cases  of  extreme  deformity  in  which  the 
s^TQptoms  are  disabling  and  in  which  the  foot  is  rigidly  held  in  the 
deformed  position  by  muscular  spasm  and  by  secondary  changes 
in  its  structure.  Such  cases,  often  considered  hopeless  as  regards  a 
cure  or  even  relief,  are  in  reality  the  most  satisfactory  from  the 
remedial  stand-point,  and  in  no  other  type  of  painful  deformity 
can  so  much  be  accomplished  by  rational  treatment  as  in  this  class. 
The  deformity  must  be  considered  as  a  dislocation  in  which  the 
astragalus  has  slipped  downward  and  inward  from  off  the  os  calcis, 
which,  in  turn,  is  tipped  downward  and  inward  and  into  a  position 
of  valgus.  The  remainder  of  the  foot  is  turned  outward,  so  that 
the  relation  of  the  leg  and  the  forefoot  is  enthely  changed;  in  fact, 
the  forefoot  is  almost  entirely  disused  (Fig.  542). 

Corresponding  to  the  duration  of  the  disability,  one  finds  accom- 
modative changes  in  the  soft  parts  and  in  the  bones,  but  such 
changes  are  by  no  means  as  marked  as  those  recorded  in  the  reports 
of  autopsies  which  have  been  made  in  cases  of  advanced  and 
irremediable  deformity.  In  fact,  by  far  the  greater  number  of 
patients  are  young  adults  in  whom  the  extreme  deformity  is  of  com- 
parati^'ely  short  duration,  and  in  whom  complete  cure  is  possible. 

Treatment. — In  the  treatment  of  such  a  condition  one  must 
first  reduce  the  dislocation  and  overcome  the  obstacles  that  con- 
tracted muscles  and  ligaments  may  offer  to  free  and  normal  motion; 


THE  RIGID   WEAK  FOOT 


719 


then  rest  must  be  assured  to  the  mjured  and  congested  parts  in 
order  to  reheve  the  patient  from  the  pain  from  which  he  has  suffered 
so  long. 

Forcible  Overcorrection. — By  far  the  most  effective  treatment  is 
forcible  overcorrection  of  the  deformity,  under  anesthesia.  When 
the. patient  is  under  the  influence  of  the  anesthetic  the  muscular 
spasm  relaxes,  and  it  will  be  seen  that  this  accounts  for  about  half 
of  the  restriction  of  motion,  the  remainder  being  caused  by  the 
adaptive  changes  that  have  been  mentioned.  The  object  of  the 
operation  is  to  overcome  the  residual  obstruction,  and  to  assure 
the  patient  against  a  relapse,  by  fixing  the  foot  for  a  sufficient  time 
in  the  position  of  extreme  adduction  and  supination,  the  attitude 
directly  opposed  to  that  which  has  become  habitual. 


Fig.  557. — The  deformed  foot  before  oper- 
ation. A,  the  projection  of  the  displaced 
astragalus  and  navicular;  B,  the  inner  mal- 
leolus; C,  the  mediotarsal  joint,  showing  the 
outward  displacement  before,  the  inward 
rotation  behind,  this  point. 


Fig.  558. — The  overcorrected 
foot,  showing  the  reversal  of  the 
lines  of  displacement.  (See  Fig. 
557.) 


This  is  the  object  of  forcible  overcorrection  as  the  first  step  in 
the  systematic  repair  of  the  disabled  mechanism;  its  principle 
must  not  be  confounded  with  forcible  correction  carried  out  with 
the  object  of  simply  remoulding  the  arch  of  the  foot,  or  in  which 
the  correction  of  the  deformity  is  the  only  object  in  view. 

One  first  extends  the  foot  forcibly,  then  flexes  it  to  the  normal 
limit,  then  abducts  and  adducts,  the  different  motions  being  carried 
out  over  and  over  until  the  rigid  foot  has  become  perfectly  flexible. 
In  cases  of  long  standing  it  is  often  necessary  to  draw  the  patient 
to  the  end  of  the  table,  so  that  the  foot  may  be  taken  between  the 
knees,  in  order  to  supply  the  required  force  by  the  thigh  muscles. 
This  forcible  manipulation  is  accompanied  by  the  audible  breaking 
of  adhesions,  and  in  favorable  cases  by  complete  disappearance  of 
the  deformity.    In  certain  instances  it  will  be  necessary  to  divide 


720       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


the  tendo-Achillis,  when,  for  example,  the  range  of  dorsal  flexion  is 
limited  by  resistant  accommodative  shortening  of  the  calf  muscles, 
or  when  there  has  been  very  great  pain  and  tenderness  at  the  medio- 
tarsal  joint,  and  it  is  desired  to  remove  the  strain  of  leverage  com- 
pletely; traumatic  cases  come  especially  under  this  head.  Occa- 
sionally also  in  resistant  cases  division  of  the  peronei  tendons  may 
be  advisable.  Tenotomy  has  one  great  advantage:  it  necessitates 
longer  fixation  in  the  plaster  bandage,  and  gives  the  patient  the 
benefit  of  rest,  and  the  opportunity  for  prolonged  after-treatment. 
When  the  passive  range  of  motion  has  been  regained,  the  foot  is 

turned  doT\-nward,  then  inward 
and  upward  into  the  position  of 
extreme  varus.  By  this  manipu- 
lation the  OS  calcis  is  drawn  under 
the  astragalus  and  thrown  into 
the  supinated  position,  and  the 
navicular  is  flexed  about  and 
under  the  head  of  the  astragalus, 
which  is  then  lifted  to  the  limit 
of  normal  flexion.  The  attempt 
is  always  made  to  bring  the  ex- 
treme outer  border  of  the  inverted 
foot  up  to  a  right  angle  with  the 
leg,  which  is  the  limit  of  normal 
flexion  in  this  attitude.  The  foot, 
very  thickly  padded  with  cotton, 
especially  between  and  about  the 
toes,  is  then  fixed  in  this  posture 
of  varus  by  a  firm  plaster-of- 
Paris  bandage  extending  to  the 
knee  (Fig.  559) .  Surprismgly  little 
discomfort,  considering  the  force 
that  it  is  sometimes  necessary  to 
apply,  is  experienced  after  the 
operation.  The  familiar  and 
often  mtense  pain,  from  which  the 
patient  has  suffered  so  long,  is  entirely  relieved  by  the  correction 
of  the  deformity;  there  is  often  a  sense  of  tension  about  the  outer 
side  of  the  ankle  and  dorsum  of  the  foot,  but  this  is  not,  as  a  rule, 
of  long  duration. 

Functional  Use  in  the  Over  corrected  Attitude. — As  soon  as  pos- 
sible, often  on  the  following  day,  the  patient  is  encom-aged  to 
stand  and  walk,  bearing  his  weight  on  the  foot.  ^Yeight-bearing 
serves  to  still  further  overcorrect  the  deformity  and  to  accustom 
the  patient  to  a  posture  entirely  different  from  that  so  long  assmned. 
]Meanwhile  the  contracted  tissues  on  the  outer  side  become  thor- 
oughly overstretched;  the  weakened  ligaments  and  muscles  on  the 


Fig.  559. — The  forcible  overcorrec- 
tion of  fiat-foot.  Tlie  proper  position 
in  the  plaster  bandage. 


THE  RIGID   WEAK  FOOT  721 

inner  side  are  relaxed,  and  the  local  irritation  rapidly  subsides 
under  the  rest  from  the  constant  injury  to  which  the  foot  has  been 
subjected. 

The  patient  is  not  confined  to  the  bed  or  house,  although  if  both 
feet  are  in  plaster  bandages,  crutches  are,  of  course,  necessary. 
The  time  that  the  foot  should  remain  in  the  overcorrected  position 
depends  upon  the  duration  of  the  deformity  and  the  severity  of 
the  symptoms,  from  two  to  six  weeks,  the  usual  time  being  about 
four  weeks.  At  the  end  of  about  three  weeks,  or  whenever  the 
patient, can  support  the  weight  on  the  plaster  bandage,  without 
a  sensation  of  discomfort,  it  is  removed;  the  foot  is  placed  in  the 
normal  attitude  and  a  cast  is  taken  for  the  brace  (Fig.  547) .  Imme- 
diately after,  the  foot  is  returned  to  the  former  position  and  the 
plaster  bandage  is  reapplied.  When  the  brace  is  ready  the  plaster 
bandage  is  finally  removed;  the  foot  is  now  in  good  position,  and  in 
many  instances  the  arch  is  exaggerated  in  depth.  For  the  first 
few  days  prolonged  soaking  in  hot  water  or  the  use  of  the  hot-air 
bath,  with  subsequent  massage  at  intervals  during  the  day,  will 
be  found  useful  in  overcoming  the  swelling  and  sensitiveness  that 
may  remain.  It  is  always  insisted  that  a  new  shoe  of  the  proper 
pattern  shall  be  obtained,  the  sole  and  heel  of  which  are  raised  a 
quarter  of  an  inch  on  the  inner  border  to  aid  in  the  balancing  of 
the  weak  foot.  The  brace  is  then  applied,  and  the  patient  is  never 
allowed  to  walk  without  its  support.  When  the  shoe  is  removed  at 
night,  he  is  instructed  to  turn  the  toes  in  and  to  bear  the  weight  on 
the  outer  side  of  the  foot  until  it  has  regained  its  strength;  in  other 
words,  the  deformity  is  never  allowed  to  recur. 

Systematic  Manipulation. — Systematic  treatment  is  then  begun 
by  the  surgeon  and  the  patient,  with  the  object  of  restoring  free 
and  painless  passive  movement  in  all  directions.  This  movement, 
which  has  been  so  long  restrained  by  deformity,  cannot  be  regained 
without  effort,  and  during  this  critical  stage,  treatment  must  be 
supervised  by  the  surgeon  himself;  if  he  trusts  to  the  patient  or  to 
his  friends  a  cure  is  out  of  the  question.  At  least  once  a  da}'  the 
full  range  of  motion  must  be  carried  out  to  the  normal  limit.  Three 
motions — abduction,  flexion,  and  extension — are  usually  free  and 
painless;  but  the  fourth,  that  of  adduction,  is  almost  invariably 
resisted  by  the  same  quality  of  muscular  resistance  that  was  present 
before  the  operation.  The  most  effective  method  of  overcoming 
this  resistance  is  as  follows:  The  patient  being  seated  in  a  chair, 
the  surgeon  sits  or  stands  before  him.  Let  us  suppose  that  the 
right  foot  is  to  be  adducted,  or,  as  the  patients  express  it,  twisted. 
The  surgeon  places  the  foot  between  his  knees;  his  right  hand 
encircles  the  heel,  the -fingers  grasping  the  projecting  os  calcis  and 
tendo-Achillis;  the  base  of  the  palm  lies  against  the  mediotarsal 
joint  on  the  inner  and  inferior  aspect  of  the  foot;  the  left  hand 
grasps  the  outer  side  of  the  forefoot  and  toes;  then,  by  steady 
46 


722       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

pressure  of  the  high  muscles,  the  forefoot  is  forced  downward 
and  inward  (adducted  and  inverted)  (Fig.  560)  over  the  fulcrum 
formed  by  the  projecting  palm,  which  lies  upon  the  right  knee,  the 
fingers  holding  the  heel  steadily  in  place.  This  inward  twisting  is 
at  first  resisted  by  voluntary  and  involuntary  muscular  spasm, 
which   gradually  gives   way  under   steady  pressure.     \Mien    the 


Fig.   560. — "  r-^visting"  the  foot. 


limit  of  adduction  has  been  reached,  the  foot  is  held  firmly  until 
all  pain  has  subsided;  then  the  patient  is  instructed  to  attempt 
^'oluntary  movements  while  the  foot  is  guided  by  the  hands;  in 
other  words,  the  patient  attempts  to  adduct  the  foot  while  the 
sm-geon  supplies  the  power,  which  in  all  cases  of  this  t^-pe  has 
been   lost.     This   passive   manipulation   to   the   extreme  limit  of 


THE  RIGID   WEAK  FOOT  723 

normal  adduction,  plantar  and  dorsal  flexion,  is  continued  from 
day  to  day  until  there  is  no  longer  a  sensation  of  pain  or  tension. 
For  as  long  as  there  is  the  slightest  spasm  or  painful  restriction  of 
passive  motion,  the  voluntary  assumption  of  proper  attitudes  is 
checked,  and  until  this  power  is  regained  there  is  danger  of  relapse. 
During  active  treatment,  therefore,  the  patient,  by  means  of  massage 
and  active  and  passive  exercises,  must  constantly  work  to  one  end, 
namely,  to  regain  the  lost  power  of  voluntary  adduction. 

The  time  necessary  to  rest  the  feet,  to  overcome  the  local  irrita- 
tion and  muscular  spasm,  to  regain,  in  part  at  least,  the  range  of 
passive  motion,  and  to  place  the  patient  in  the  same  position,  as 
regards  a  cure,  as  in  the  milder  types  of  deformity,  is  from  three 
to  six  weeks.  Usually  the  patients  are  told  that  a  month  will  be 
necessary,  and  that  at  the  end  of  that  time  they  may  return  to 
work,  free  from  pain  and  from  the  danger  of  relapse,  and  that  the 
feet  will  constantly  grow  stronger  under  the  work  which  was  before 
too  great  for  their  strength.  The  time  necessary  to  reeducate 
the  adductor  muscles  in  their  proper  function  depends,  in  great 
degree,  upon  the  intelligence  and  persistence  of  the  patient. 
Although  in  after-treatment  massage  and  special  exercises  are  of 
benefit,  the  essentials  are  very  simple;  they  are  an  effective  brace,  a 
proper  shoe,  the  passive  manipulation  that  has  been  described 
until  its  object  has  been  attained,  and  the  proper  walk,  the  best 
and  easiest  of  exercises.  Finally,  one  must  force  into  the  patient's 
understanding  the  method  of  protecting  the  weak  foot  by  the 
alternation  of  strain,  and  by  proper  postures. 

Other  Varieties  of  Rigid  Weak  Foot.— The  foot  which  is  fixed 
in  the  abducted  position  without  depression  of  the  longitudinal 
arch  is  simply  one  variety  of  the  rigid  weak  foot,  which  should 
be  treated  in  the  same  manner.  It  may  be  stated,  also,  that  a 
very  large  proportion  of  the  so-called  chronic  sprains  of  the  ankle 
are  of  this  type,  and  that  the  disability  will  yield  very  readily  to 
treatment,  conducted  with  the  purpose  of  restoring  impaired 
function,  in  the  manner  that  has  been  indicated. 

In  certain  instances  the  apex  of  the  deformity  lies  in  front  of  the 
astragalonavicular  joint,  in  the  navicular  cuneiform  region,  and  the 
internal  cuneiform  bone  may  be  enlarged  and  sensitive  to  pressure. 
Such  cases  should  be  treated  on  the  same  general  principles  as  the 
ordinary  variety. 

In  rare  instances  marked  depression  of  the  arch  is  accompanied 
by  flexion  contraction  of  the  great  toe,  as  if  the  result  of  an  attempt 
to  support  the  weak  arch.  This  was  described  by  Nicoladoni  as 
hammer-toe  flat-foot  (Fig.  543).  The  association  of  painful  great 
toe  (hallux  rigidus)  and  weak  foot  is  mentioned  elsewhere. 

There  are  other  cases  in  which  the  deformity  of  weak  foot  is 
complicated  by  chronic  rheumatism,  gonorrheal  arthritis,^  or 
similar  affections  of  which  the  evidence  is  seen  in  various  joints, 


724       DISABILITIES  AXD  DEFORMITIES  OF   THE  FOOT 

but  in  which  the  pain  and  discomfort  seem  to  be  concentrated  in 
the  feet,  which  are  absolutely  stiff  and  deformed.  In  such  cases 
one  can  hardly  expect  a  complete  ciu-e;  but  although  the  function 
of  leverage  may  not  be  regained,  still  one  may  hope,  by  overcoming 
the  deformity,  to  hold  the  weight  of  the  body  in  its  proper  relation 
to  the  foot,  so  that  the  pain  of  a  progressive  dislocation  may  not  be 
added  to  the  pain  of  disease.  In  a  nmnber  of  instances  forcible 
correction  has  been  employed  by  the  ^\Titer  in  cases  of  this  type, 
and  in  all  the  improvement  in  the  general  condition,  consequently 
in  the  resistance  to  the  disease,  after  the  relief  of  the  local  pain 
and  discomfort,  has  been  very  great. 

Between  the  two  classes  of  cases,  the  mild  and  the  severe,  one 
finds  every  grade  of  deformity.  All  cases  in  which  there  is  marked 
muscular  spasm,  local  sensitiveness,  and  swelling  require  temporary 
rest;  in  many  instances  simply  rest  from  functional  use  combined 
with  massage;  in  others,  rest  in  a  plaster  bandage  in  the  adducted 
attitude.  In  the  milder  and  ordinary  class  of  cases  the  use  of  a 
brace  and  shoe  will  relieve  spasm  and  pain,  and  the  range  of  motion 
can  usually  be  regained  by  manipulation,  passive  motion,  and  by 
the  proper  use  of  the  foot. 

Occasionally,  even  in  childhood,  one  ma}'  encounter  marked 
limitation  of  normal  motion,  particularly  in  dorsal  flexion,  caused 
by  actual  shortening  of  the  calf  muscle.  This  may  be  the  accommo- 
dative adaptation  to  long-standing  deformity;  in  other  instances 
it  would  appear  to  be  the  result  of  a  slight  and  unnoticed  neuritis 
or  anterior  poliomyelitis,  which  has  resulted  in  muscular  inequality 
or  even  to  the  habitual  use  of  high  heels,  and  disuse  of  the  normal 
range  of  dorsal  flexion.  If  the  contraction  does  not  yield  readily 
to  manipulation  or  to  mechanical  stretching,  forcible  correction 
and,  if  necessary,  tenotomy  should  be  employed  in  the  manner 
already  described ;  for  whatever  may  be  the  cause,  it  is  again  empha- 
sized that  obstruction  to  motion  in  every  direction  must  be  over- 
come before  a  complete  cure  is  possible. 

Adjuncts  in  Treatment. — It  must  be  apparent  that  in  many 
instances  the  anatomical  cm"e  of  the  weak  foot  is  impracticable, 
either  because  of  the  want  of  energy  or  opportunity  on  the  part 
of  the  patient,  or  because  of  the  local  or  general  conditions,  types 
familiar  in  out-patient  practice. 

The  Thomas  Treatment. — In  such  cases  raising  and  strengthening 
the  inner  side  of  the  shoe  by  the  wedge-shaped  leather  sole,  as  used 
hj  Thomas,  splints  the  painful  foot  and  aids  in  relieving  the  strain. 
A  diagonal  heel  of  which  the  inner  border  extends  forward  beneath 
the  arch  is  a  less  offensive  if  less  eftecti^'e  support  of  the  same  class. 

Plaster  Strapping. — If  the  symptoms  are  more  acute  the  adhesive- 
plaster  strapping,  as  advocated  by  Cottrell  and  Gibney  for  the  treat- 
ment of  sprains,  is  often  of  service,  although  it  is  applied  in  a  different 
manner,  and  with  a  different  object  in  view.     One  end  of  a  strip 


THE  RIGID   WEAK  FOOT 


725 


of  adhesive  plaster,  about  fifteen  inches  long  and  three  inches  wide, 
is  applied  to  the  outer  side  of  the  ankle  just  below  the  external 
malleolus;  the  foot  is  then  adducted  as  far  as  possible,  and  the  band 
is  drawn  tightly  beneath  the  sole  up  the  inner  side  of  the  arch  and 
leg,  and  is  stayed  in  this  position  by  one  or  two  plaster  strips  about 
the  calf  (Fig.  561).  Narrow  plaster  straps  are  then  applied  about 
the  arch  and  ankle,  in  the  figure-of-eight  manner,  and  a  bandage  is 
applied.  The  object  of  the  dressing  is  to  aid  in  holding  the  foot  in 
the  improved  position  by  the  support  and  suggestiveness  of  the 
plaster,  ^nd  to  provide  the  firm  compression  about  the  arch  that  is 


Fig.  561. — ^Method  of  applying  the  plaster  strapping  to  hold  the  foot  in  the  adducted 

attitude. 


always  agreeable  to  the  sufi^erer  from  weak  foot.  This  treatment, 
combined  with  the  built-up  shoe,  is  often  very  effective  in  overcom- 
ing the  acute  and  disabling  symptoms  of  the  weak  and  injured  foot, 
which  are,  as  has  been  stated,  often  the  result  of  extra  strain  or 
injury;  in  other  words,  a  sprain  of  a  weak  foot.  Consequently, 
when  these  symptoms  are  relieved,  the  patient  who  has  become 
habituated  to  the  weakness  and  deformity  considers  himself  cured. 
By  persistent  manipulation  and  subsequent  support  with  the 
adhesive  plaster  one  may  overcome  the  deformity  in  the  majority 
of  cases.  When  this  is  accomplished  the  brace  is  applied  and  the 
further  treatment  that  has  been  described  is  continued.     Forcible 


726        DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT 

correction  under  anesthesia  is,  however,  preferable  in  cases  of  the 
more  resistant  type. 

Operative  Treatment. — The  various  cutting  operations  for  the 
rehef  of  flat-foot  do  not  call  for  extended  comment.  The  tibialis 
anticus  tendon  has  been  transplanted  to  the  periostium  of    the 


Fig.  563 


Fig.  564. — Shape  of  wedge. 


Fig.  565 

Figs.  562-565. — Wedge  removed  from  scaphoid  and  inserted   into    the   os   calcis. 

(Perth.) 


scaphoid.^  Arthrodesis  of  the  astragaloscaphoid  articulation  assured 
by  bone  pegging  is  also  advocated."  The  typical  operation,  the 
removal  of   a  wedge    from    the    astragalonavicular  region,   aims 

'  E.  Mliller:    Beitr.  z.  klin.,  1914,  Ixxxv,  424. 
2  Soule:    Am.  Jour.,  Orth.  Surg.,  April,  1917. 


THE  RIGID   WEAK  FOOT  727 

simply  at  removal  of  the  deformity.  It  should  be  restricted  to 
those  cases  in  which  the  adaptive  changes  are  so  marked  that 
functional  cure  is  impossible.  A  more  conservative  form  of  operation 
is  that  of  Perth^  as  illustrated  in  Figs.  562-565.  A  wedge  of  bone  is 
removed  from  the  scaphoid  and  inserted  into  the  anterior  external 
extremity  of  the  os  calcis. 

The  operation  of  advancement  of  the  posterior  extremity  of  the 
OS  calcis,  as  proposed  by  Gleich,  in  order  that  it  may  be  placed  in 
relation  to  the  leg  somewhat  like  that  of  Pirogoff  amputation, 
offers  little  hope  of  ultimate  cure;  for  since  the  disability  is  not  due 
to  primary  depression  of  the  arch,  it  can  hardly  be  cured  by  exag- 
gerating its  depth  in  this  manner.  Supramalleolar  osteotomy,  in 
which  the  bones  of  the  leg  are  divided  above  the  ankle,  and  the  distal 
extremity  turned  inward,  with  the  aim  of  directing  the  weight 
toward  the  outer  border  of  the  foot,  has  been  advocated  by  Tren- 
delenburg. In  practice  the  operation  is  by  no  means  always  suc- 
cessful, while  the  bow-leg  that  results  if  the  object  is  attained  is  an 
unfortunate  accompaniment  of  the  treatment.  It  may  be  mentioned 
in  this  connection  that  fracture  at  the  ankle-joint,  followed  by  faulty 
union  in  a  position  of  valgus,  is  a  form  of  traumatic  weak  foot  that 
may  be  cured  by  this  operation.  In  operative  treatment  the  pro- 
longed rest  must  be  taken  into  consideration,  as  explaining  in  part 
the  immediate  favorable  effect  of  whatever  procedure  is  adopted. 

In  conclusion,  the  following  points  are  again  emphasized:  The 
weak  foot  in  all  its  grades  is  characterized  by  the  pejsistent  attitude 
of  abduction,  an  attitude  that  must  be  corrected  if  cure  is  to  be 
accomplished.  The  depth  of  the  arch  is  of  minor  importance  and 
for  this  reason  the  term  flat-foot  which  has  attracted  attention  to 
this  element  of  deformity  rather  than  to  functional  disability  should 
be  discarded. 

1  Deutsch.  Ztschr.  f.  Chir.,  April  12,  1913. 


CHAPTER   XXI. 

DISABILITIES  AXD   DEEORMITIES  OE  THE   EOOT 
(Coxtit^ited). 

THE   HOLLOW   OR   CONTRACTED   FOOT. 

Synonyms. — Talipes  plantaris,  talipes  ca^-us. 

The  depth  of  the  arch  and  the  corresponding  area  of  the  bear- 
ing smface  of  the  sole  vary  greatly  in  different  individuals,  and, 
although  marked  differences  in  contom'  and  function  are  included 
within  a  normal  range,  yet,  as  a  rule,  the  low  arch  is  characterized 
by  relaxation  and  weakness  of  structiu'e.  while  the  high  arch 
implies  a  corresponding  contraction  and  loss  of  normal  elasticity. 

The  hollow  or  contracted  foot  may  be  divided  into  two  classes 
— the  primary  and  the  secondary.  In  the  fii'st  class  the  simple 
exaggeration  of  the  arch  i  talipes  arcuatus)  is  the  only  change  from 
the  normal  condition.  In  the  second  the  high  arch  is  combined 
with  limitation  of  the  range  of  dorsal  flexion  at  the  ankle-joint 
(talipes  plantaris — Eisher  i . 

Etiology. — The  simple  hollow  foot  may  be  an  inherited  pecu- 
liarity. The  depth  of  the  arch  may  be  exaggerated  by  the  habitual 
use  of  high  heels  (postm'al  equinus),  or  by  excessive  use  of  the  calf 
muscles,  as  by  professional  dancers. 

The  secondary  A-ariety,  in  which  the  hollow  foot  ir>  combined 
with  slight  equinus,  may  be  induced  by  habitual  use  of  high  heels 
and  consequent  habitual  disuse  of  dorsal  flexion,  but  if  it  is  marked 
its  origm  may  be  traced  in  many  instances  to  a  mild  and  transient 
form  of  anterior  poliomyelitis  or  netnitis  in  early  childhood.  This 
causes  temporary  weakness  of  the  anterior  group  of  muscles  of  the 
leg,  and  thus  a  slight  toe-drop,  followed  by  secondary  contraction 
of  the  tissues  of  the  sole  and  of  the  muscles  of  the  calf.  In  the 
history  of  many  of  these  patients  it  will  appear  that  after  recovery 
from  scarlatina  or  other  contagiotis  or  infectious  disease  the  child 
seemed  weak  or  awkward.  These  SATiiptoms  became  less  marked 
or  practically  disappeared:  yet  a  trace  remained,  although  not  of 
sufficient  importance  to  call  for  treatment,  until  adolescence  or 
adult  life,  when  the  greater  strain  and  weight  ptit  upon  the  feet 
brought  to  light  the  latent  disability.  The  affection  may 
undoubtedly  develop  in  later  years  as  the  result  of  neuritis,  or 
of  gout  or  rhemnatism.  It  may  be  caused  by  a  sprain  or  fracture 
of  the  ankle,  and  it  may  be  a  result  of  habitual  postme  in  compensa- 
tion for  a  limb  shortened  by  injiny  or  disease. 


THE  HOLLOW  OR  CONTRACTED  FOOT 


729 


The  exaggerated  arch  which  is  a  part  of  a  more  important 
deformity,  as  of  equinovarus  or  calcaneus,  or  that  which  is  simply 
one  of  many  distortions  caused  by  diseases  of  the  nervous  apparatus, 
does  not  belong  to  the  class  of  disability  under  consideration. 

Symptoms. — ^The  simple  hollow  foot  often  exists  without  symp- 
toms; in  fact,  it  is  usually  considered  as  a  particularly  well-formed 
foot  rather  than  a  deformity.  The  common  complaint  in  these  cases 
is  that  one  is  unable  to  buy  comfortable  shoes  because  the  ordinary 
shoe  does  not  conform  to  the  arch,  or  because  the  leather  presses 
on  the  dorsum  of  the  foot.  The  convexity  of  the  dorsum,  of  course, 
corresponds  to  the  depth  of  the  arch;  in  many  instances  the  cunei- 


FiG.  56G. — The  contracted  foot  of  slight  degree. 


form  bones  project  sharply  beneath  the  skin,  and  painful  pressure 
points  or  even  inflamed  biusse  in  this  locality  may  cause  discom- 
fort. 

In  the.  well-marked  cases  in  which  the  weight  is  borne  entirely 
on  the  heel  and  the  front  of  the  foot,  calluses  and  corns  usually 
form  at  the  centre  of  the  heel  and  beneath  the  heads  of  the  meta- 
tarsal bones.  The  patient  may  complain  of  neuralgic  pain  about 
the  great  toe,  the  metatarsal  arch,  or  in  the  sole  of  the  foot.  The 
gait  is  often  ungraceful,  as  the  patient  walks  heavily  upon  the 
heels  with  the  feet  tm-ned  outward.  In  such  cases  "the  ankles 
may  be  weak  and  turn  easily."  In  the  more  advanced  cases  of  this 
type  the  foot  may  assume  the  position  of  valgus  when  weight  is 


730       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

borne,  so  that  the  more  noticeable  s^^llptoms  are  those  of  the  weak 
foot  or  so-called  flat-foot. 

Contracted  foot,  of  the  more  severe  grade,  is  almost  always 
accompanied  by  a  certain  limitation  of  dorsal  flexion;  and  as  the 
shortening  of  the  plantar  fascia  is  often  more  marked  at  its  inner 
border,  a  slight  inversion  of  the  forefoot  or  varus  may  be  present 
also. 

^'NHien  the  exaggerated  arch  is  combined  with  limitation  of  dorsal 
flexion  the  deformity  is  usually  greater.  This  limitation  may  be  very 
slight,  or  it  may  be  well-marked;  and  a  slight  degree  of  permanent 
equinus  even  may  be  present,  but  so  slight  that  it  does  not,  as  a 
rule,  attract  attention. 

This  tj'pe  of  the  contracted  foot  was  first  clearly  described  by 
Shaffer,  in  1885,  under  the  title  of  "non-deforming  club-foot,"^ 
and  later  by  Fisher,  of  London,  as  "talipes  plantaris." 

The  sjTQptoms  are  similar  to  those  of  the  simple  hollow  foot, 
but  they  are  almost  always  more  marked.  The  gait  is  awkward 
and  jarring,  the  feet  being  tiu-ned  outward  to  an  exaggerated  degree. 
The  patient  is  easily  fatigued,  and  often  complains  of  the  weakness 
about  the  ankle  and  inner  side  of  the  arch,  characteristic  of  the 
weak  foot,  and  of  sensations  of  tu'e  and  strain  in  the  calf  of  the  leg. 
The  discomfort  from  corns,  the  pain  referred  to  the  metatarsal 
region,  the  great  toe,  and  to  the  sole  of  the  foot  have  been  described 
already. 

On  examination,  the  exaggeration  of  the  arch  is  evident,  and  an 
imprint  of  the  sole  shows  that  the  weight  is  borne  entirely  on  the 
heel  and  on  the  heads  of  the  metatarsal  bones,  which  may  be  very 
prominent  beneath  the  thickened  skin,  as  if  the  subcutaneous  fat 
had  been  absorbed.  The  anterior  metatarsal  arch  is  often 
obliterated,  and  the  toes  are  usually  habitually  dorsiflexed  at  the 
first  phalanges,  the  permanent  flexion,  with  the  resulting  pressure 
against  the  leather  of  the  shoe  being  indicated  by  a  row  of  corns 
upon  their  dorsal  surfaces  (Fig.  567). 

The  contracted  plantar  fascia  may  be  demonstrated  by  forcible 
dorsal  flexion  of  the  foot,  when  the  tense  bands,  in  many  instances 
ver}'  sensitive  to  pressure,  may  be  felt  beneath  the  skin. 

On  testing  the  movements  of  the  foot,  the  limitation  of  dorsal 
flexion,  both  of  the  voluntary  and  the  passive  range,  will  be  evident. 
In  voluntary  flexion  the  toes  are  drawn  .up  and  the  tendons  are 
plainly  seen  on  the  dorsum,  showing  the  eflort  made  by  the  acces- 
sory muscles  to  overcome  the  abnormal  resistance. 

The  limitation  of  dorsal  flexion  may  be  demonstrated  in  the 
manner  suggested  by  Shaffer,  by  asking  the  patient  to  flex  the  feet 
while  standing  erect  with  the  back  to  the  wall,  when,  in  spite  of  the 
eflort  made,  "the  feet  remain  glued  to  the  floor." 

1  New  York  Med.  Rec,  May  23,  1885. 


THE  HOLLOW  OR  CONTRACTED  FOOT 


731 


Treatment. — In  the  ordinary  form  of  contracted  foot,  as  has 
been  stated,  the  disabihty  is  much  more  marked  than  the  deformity; 
and  the  disabihty  is  due  to  secondary  changes  in  the  structure  of 
the  foot,  by  which  its  elasticity  is  impaired.  If  this  can  be  restored 
in  some  degree,  permanent  rehef  will  follow.  If  the  simple  hollow 
foot  (cavus),  or  the  secondary  type  (plantaris),  were  discovered  in 
early  childhood,  massage,  and  methodical  stretching  would,  in  all 
probability,  be  sufficient  to  relieve  the  contractions;  but,  as  a  rule, 
no  symptoms  are  noticed  until  later  life.  Even  then,  especially 
in  the  simple  form,  they  are  often  slight  and  may  be  relieved  by  a 
shoe  with  a  broad  heel  and  a  high  (Spanish)  arch  or  by  a  foot  plate 
that  equalizes  the  pressure  on  the  sole. 


Fig.  567. — The  hollow  foot,  showing  contraction  of  the  toes. 

In  the  more  advanced  cases  of  the  milder  type  methodical  forcible 
manual  stretching  may  elongate  the  tissues  sufficiently  to  relieve 
the  symptoms.  The  Shaffer^  "traction  shoe"  may  be  used  with 
advantage  for  the  same  purpose.  In  the  more  resistant  cases, 
however,  division  of  the  contracted  parts  and  forcible  correction 
of  deformity  are  indicated. 

Operative  Treatment. —  The  patient  having  been  anesthetized,  a 
tenotomy  knife  is  introduced  beneath  the  skin  to  the  inner  side 
of  the  central  band  of  fascia.  This  is  divided  by  a  sawing  motion, 
and  if  on  forced  dorsal  flexion  other  tense  bands  appear  they  are 
divided  also.  Forcible  massage,  with  the  aim  of  making  the  foot 
flexible  and  reducing  the  depth  of  the  arch,  is  then  employed.    If 


1  New  York  Med.  Jour.,  March  5,  1887. 


732       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

more  force  is  required  the  Thomas  wrench  may  be  used  as  in  the 
treatment  of  chib-foot;  the  object  being  to  elongate  the  foot,  to 
remove  the  contraction,  and  thus  by  increasing  the  area  of  bearing 
surface  to  reheve  the  painful  pressure  on  the  heads  of  the  metatarsal 
bones.  If  the  contraction  of  the  tendo-Achillis  cannot  be  overcome 
by  forcible  manipulation  it  may  be  divided  or  elongated.  In  nearly 
all  cases  of  this  type  the  toes  are  contracted  often  to  a  degree  of 
hammer-toe  deformity  and  the  metatarsal  arch  is  replaced  by  a 
convexity  doTv^iward.  This  deformity  may  be  corrected  by  manipu- 
lation and  if  necessary  by  subcutaneous  division  of  the  extensor 
tendons.  The  toes  are  then  vigorously  stretched  and  are  then 
forced  downward,  while  the  metatarsal  extremities  are  pushed 
upward.  A  plaster  bandage  is  then  applied  to  hold  the  extended 
toes  in  plantar  flexion  and  the  foot  in  dorsal  flexion.  A  thin  board 
may  be  incorporated  in  the  bandage,  in  order  that  firm  and  even 
pressure  may  be  exerted  upon  the  sole.  As  soon  as  possible,  often 
on  the  following  day,  the  patient  is  encouraged  to  walk  about, 
in  order  that  the  pressure  of  the  body  weight  may  be  utilized  to 
flatten  the  foot  still  more,  while  its  tissues  are  in  a  yielding  condition. 

The  bandage  may  be  continued  for  six  weeks,  or,  if  the  tendo- 
Achillis  has  been  divided,  until  its  repair  is  complete.  A  well- 
fitting  shoe  should  be  worn,  and  methodical  massage  and  stretching 
of  the  tissues  should  be  persistently  employed,  particularly  with  the 
aim  of  restoring  the  normal  flexion  of  the  toes.  A  long  metal  foot 
plate  extending  to  the  extremity  of  the  sole  presenting  a  convexity 
beneath  the  metatarsophalangeal  articulations  is  an  essential  aid  in 
restoring  the  normal  contour. 

By  this  treatment  the  s^Tnptoms  may  be  relieved,  and  in  many 
instances  a  return  to  the  normal  shape  and  function  can  be  assured. 

WEAKNESS  AND  DEPRESSION  OF  THE  ANTERIOR  META- 
TARSAL  ARCH. 

Anterior  Metatarsalgia  and  Morton's  Neuralgia. — A  peculiar 
spasmodic  pain  about  the  fourth  toe  was  described  by  ]*kIorton, 
of  Philadelphia,  long  before  its  predisposing  and  exciting  causes 
were  understood.  For  this  reason  a  description  of  the  symptoms 
may  with  advantage  precede  a  consideration  of  the  weakness  of 
T\diich  they  are  usually  the  result. 

T^-pical  cases  of  ]\Iorton's^  painful  affection  of  the  foot  are 
characterized  by  a  sudden  cramp-like  pain  in  the  region  of  the 
foiu-th  metatarsophalangeal  articidation. 

The  pain  may  begin  as  a  bm-ning  sensation  beneath  the  toe, 
as  a  nimib  or  tingling  feeling,  as  a  sudden  cramp,  or  as  a  peculiar 
feeling  of  discomfort  about  the  articulation  that  increases  in  severity 

1  T.  G.  Morton:  Am.  Jour.  Med.  Sc,  August,  1876. 


WEAKNESS  OF   THE  ANTERIOR  METATARSAL  ARCH       733 

until  it  becomes  almost  unbearable.  Kt  first  the  pain  is  confined 
to  the  neighborhood  of  the  affected  joint,  but  unless  it  is  relieved 
it  radiates  to  the  extremity  of  the  toe,  to  the  dorsum  of  the  foot, 
or  up  the  leg.  In  many  instances  the  onset  of  the  pain  is  preceded 
by  the  sensation  of  something  moving  or  slipping  in  the  foot;  in  some 
cases  the  pain  may  be  induced  by  sudden  movements,  missteps,  or 
by  long  standing,  and  in  practically  all  the  cases  the  pain  is  felt 
onh'  when  the  shoes  are  worn.  The  frequency  of  the  recurrent 
cramp  varies;  in  some  cases  it  appears  only  at  infrequent  intervals; 
in  others* it  practically  disables  the  patient.  When  the  "cramp" 
habit  has  been  acquired,  very  slight  causes  may  induce  the  pain — 
for  example,  a  thin-soled  shoe,  a  hot  pavement,  "the  sticking  of  the 
sock  to  the  foot,"  and  the  like — but,  as  has  been  stated,  except  in 
the  very  advanced  and  chronic  cases,  the  pain  is  never  felt  except 
when  the  shoe  is  worn. 

To  relieve  the  pain  the  patient  removes  the  shoe,  rubs  and 
compresses  the  front  of  the  foot,  flexes  and  extends  the  toes,  and  the 
like.  After  the  cramp  is  relieved  a  sensation  of  soreness  remains, 
and  occasionally  slight  swelling  may  appear,  but  in  most  instances 
there  are  no  external  signs,  although  the  afFected  articulation  is 
usually  sensitive  to  deep  pressure  at  all  times. 

The  more  comprehensive  term,  anterior  metatarsalgia,  a  term 
suggested  by  Poulosson,  of  Lyons,  in  1889,  may  be  employed  to 
include  Morton's  neuralgia,  and  similar  symptoms  of  pain  and  dis- 
comfort about  the  anterior  metatarsal  arch.  For  in  many  instances 
the  cramp-like  pain  is  referred  to  other  points,  for  example,  to  several 
adjoining  joints,  or  the  discomfort  caused  apparently  by  direct 
pressure  on  the  bones  of  the  weakened  arch  may  be  more  disabling 
than  the  irregular  attacks  of  neuralgic  pain  characteristic  of 
Morton's  affection. 

Etiology  and  Pathology. — In  78  cases  of  anterior  metatarsalgia 
in  which  the  location  of  the  pain  was  noted,  it  was  referred  to  the 
fourth  metatarsophalangeal  articulation  in  60;  to  the  third  and 
fourth  articulation  in  6;  to  the  second,  third,  and  fourth  in  6,  and 
in  but  6  was  the  fourth  articulation  free  from  pain.  The  pain  is 
most  often  unilateral,  or,  if  the  other  foot  is  affected,  it  is  usually 
after  a  considerable  interval. 

The  affection  is  more  common  in  females  than  in  males.  Of  84 
cases,  64  were  in  women  and  20  were  in  men. 

Anterior  metatarsalgia  is  not  an  affection  of  early  life,  the  average 
age  in  the  reported  cases  being  more  than  thirty  years.  It  is  far 
more  common  in  private  than  in  hospital  practice,  and  not  infre- 
quently the  patients  are  of  a  distinctly  nervous  type.  In  many 
instances  it  is  supposed  to  be  a  family  inheritance.  The  affection 
is  usually  extremely  chronic.  Occasionally  the  symptoms  may 
cease  spontaneously,  and  in  such  instances  a  particular  pattern  of 
shoe  usually  receives  the  credit  of  the  cure. 


734       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

Morton  considered  the  disability  to  be  a  painful  affection  of  the 
plantar  nerves  due  to  compression  or  pinching  by  the  adjoining 
fourth  and  fifth  metatarsophalangeal  articulations.  This  compres- 
sion was  explained  by  the  anatomical  construction  of  the  foot — 
i.  e.,  the  mobility  of  the  fifth  metatarsal  bone  which  allowed  it  to 
roll  above  and  under  the  fourth,  its  relative  shortness  which  allowed 
the  head  and  base  of  the  adjoining  phalanx  to  be  brought  against 
the  adjoining  head  and  neck  of  the  fourth  bone,  and,  finally,  by 
the  peculiar  distribution  of  the  external  plantar  nerve  between 
these  bones  that  made  it  or  its  fibres  more  liable  to  injury.  This 
natural  mobility  and  thus  the  predisposition  to  compression  might 
be  exaggerated  by  a  sprain,  or  possibly  by  rupture  of  the  transverse 
metatarsal  ligament,  or  the  pain  might  be  induced  by  wearing  tight 
shoes,  but  in  many  instances  no  cause  could  be  assigned.  On  this 
theory  Morton  advocated  excision  of  the  head  of  the  fourth  meta- 
tarsal bone  to  remove  the  point  of  counter-pressure.  This  operation 
has  been  performed  many  times,  but  practically  no  pathological 
changes  in  the  resected  bone  or  in  the  surrounding  parts  have  ever 
been  discovered. 

In  more  recent  years  the  true  significance  of  IMorton's  neuralgia 
and  of  similar  pains  in  the  front  of  the  foot  has  been  made  more 
clear  by  the  study  of  the  relation  of  weakness  of  the  anterior  trans- 
verse metatarsal  arch  to  the  symptoms.  Attention  was  first  called 
to  this  point  by  Poulosson,  and  again  by  Roughton,  Woodruff,  and 
others,  and  in  a  much  more  thorough  and  convincing  manner  by 
Goldthwait,!  in  1894. 

The  Anterior  Metatarsal  Arch. — In  the  normal  foot  the  two  central 
metatarsal  bones,  the  second  and  third,  are  slightly  longer  and  on  a 
higher  plane  than  their  fellows.  On  the  sole  of  the  foot  the  arch 
is  shoA\n  by  the  depression  on  the  outer  side  of  the  muscular  projec- 
tion of  the  great  toe-joint.  When  weight  is  borne  all  the  metatarsal 
bones  are  on  the  same  plane  and  the  arch  is  obliterated,  but  when 
the  weight  is  removed  the  arch  is  restored  by  a  certain  natural 
resiliency.  In  walking  and  standing  the  weight  falls  in  the  neighbor- 
hood of  the  head  of  the  third  metatarsal  bone,  as  shown  by  a  thicken- 
ing of  the  skin  beneath  it,  but  the  strain  on  the  metatarsal  arch  is 
relieved  somewhat  by  the  balancing  action  of  the  muscles  about 
the  first  and  fifth  metatarsal  bones,  the  inner  and  outer  supports 
of  the  arch,  and  by  the  active  assistance  of  the  toes  themselves. 
When  the  arch  is  weak  or  broken  down  this  natural  resiliency  is  lost, 
and,  in  some  instances,  the  centre  of  the  forefoot  is  not  only 
depressed  but  it  is  fixed  in  this  abnormal  attitude. 

In  the  ordinary  tj^pe  of  depressed  anterior  arch  the  deformity 
may  be  shown  by  an  imprint  of  the  foot,  in  which  the  flabby  tissues 
of  the  depressed  arch  encroach  upon  the  clear  space  representing 

1  Boston  Med.  and  Surg.  Jour.,  cxxxi,  233. 


WEAKNESS  OF   THE  ANTERIOR  METATARSAL  ARCH  735 

the  longitudinal  arch.  In  many  instances,  however,  the  imprint 
of  the  foot  subject  to  Morton's  neuralgia  may  be  to  all  intents 
normal,  and,  on  the  other  hand,  depression  of  the  metatarsal  arch, 
one  of  the  very  common  results  of  improper  shoes,  may  be  present, 
yet  unaccompanied  by  pain  or  discomfort. 

Depression  of  the  anterior  arch  induces  discomfort  because  of 
abnormal  pressure  upon  the  persistently  depressed  articulations 
from  beneath  and  it  predisposes  to  pain,  as  the  writer  has  endeavored^ 
to  explain,  because  the  metatarsophalangeal  joints  of  an  habitually 
depressed  arch  are  exposed  to  the  direct  lateral  compression  of  a 
narrow  or  ill-shaped  shoe. 


Fig.  568. 


-Position  of  the  fingers  corresponding  to  dorsifiexion  of  the  toes,  an  atti- 
tude in  which  lateral  pressure  causes  pain. 


This  point  may  be  illustrated  in  the  hand.  When  lateral  pressure 
is  applied,  the  hand  is  folded  together  and  the  anterior  metacarpal 
arch  is  increased  in  depth,  but  if  the  fingers  are  dorsiflexed  so  that  it  is 
fixed  in  a  depressed  position,  then  lateral  compression  causes  great 
pain  at  all  the  articulations  (Fig.  568) ;  or  if  one  finger  is  dorsiflexed 
and  the  corresponding  metacarpal  bone  is  thus  forced  below  the 
level  of  its  fellows,  lateral  compression  causes  pain  at  the  compressed 
joint.  Or  if  the  metacarpal  bone  of  the  little  finger  is  made  to  over- 
ride the  fourth,  lateral  pressure  causes  pain  usually  of  a  more  acute 
character  than  at  the  other  joints,  because  the  opportunity  for 
direct  pressure  is  more  favorable.^  Finally,  if  firm  pressure  is  made 
upon  one  or  the  other  side  of  the  head  of  the  depressed  metacarpal 
bone  of  the  dorsiflexed  finger  in  the  palm  of  the  hand,  a  point  of 
sensitiveness,  representing  apparently  the  digital  nerve,  can  be 
made  out.  The  same  experiments  may  be  tried  upon  the  foot  with 
the  same  results,  and  it  would  seem  to  make  clear  the  mechanism 

1  New  York  Med.  Rec,  August  6,  1898. 

2  This  anatomical  peculiarity  is  well  known  to  school-boys. 


736       DISABILITIES  AXD  DEFORMITIES  OF   THE  FOOT 

of  the  pain  of  ^Morton's  neuralgia  and  the  alhed  forms  of  discomfort 
at  the  front  of  the  foot. 

Anterior  metatarsalgia  is  in  most  instances  the  resuh  of  weak- 
ness or  depression  of  the  anterior  metatarsal  arch  as  a  whole  or  in 
part,  and  the  quality  of  the  pain  corresponds  fairly  to  the  form 
of  weakness  or  deformity.  If,  for  example,  the  entire  arch  is  rigidly 
depressed,  as  after  certain  inflammatory  affections  of  the  joints, 
the  discomfort  is  likely  to  be  caused,  in  great  degree,  by  the  direct 
pressure  of  the  sensitive  depressed  metatarsophalangeal  joints 
on  the  sole  of  the  shoe;  or,  if  lateral  pressure  is  exerted  as  well, 
the  discomfort  or  pain  may  be  referred  to  the  metatarsal  arch  in 
general.  If  the  metatarsal  arch  is  weakened,  depressed,  and 
broadened,  but  not  rigid,  the  discomfort  is  often  referred,  as  in 
the  precedmg  instance,  to  the  centre  of  the  arch,  and  this  discom- 
fort is  increased,  in  some  instances,  by  a  painful  callus  representing 
abnormal  pressm-e  at  this  point.  "Burning  paiu"  at  night  after 
overuse  is  a  common  s\TQptom  of  this  class  of  cases.  If  one  of  the 
metatarsal  bones  falls  below  its  fellows,  the  lateral  pressure  of  a 
narrow  shoe  may  cause  neuralgic  pain  at  this  joint,  but  in  many 
cases  in  which  the  anterior  arch  is  depressed  the  patient  makes 
but  little  complaint  of  pain.  In  certain  instances,  more  particu- 
larly those  of  ^lorton's  tA'pical  neuralgia,  the  foot  may  appear  to 
all  intents  normal;  in  such  cases  it  may  be  iuf erred  that  the  sharp 
and  characteristic  pain  is  caused  by  pressure  applied  to  the  over- 
riding fifth  metatarsal  bone,  just  as  similar  pain  is  felt  if  the  hand 
is  suddenly  compressed  while  the  fifth  metacarpal  bone  is  in  the 
same  position.  The  theory  is  the  more  satisfactory  because  it 
explains  the  s^Tiiptoms  and  indicates  the  principles  of  treatment: 
for  example,  the  sensation  of  something  slipping  or  moving,  the 
necessity  for  the  removal  of  the  shoe  to  flex  and  extend  the  toes 
and  to  compress  the  foot,  apparently  with  the  instinctive  aim  of 
replacing  a  depressed  arch,  or  a  misplaced  bone  in  the  arch.  It 
would  also  explain  how  the  shoe  may  be  the  most  direct  of  the  excit- 
ing causes  of  the  deformity,  in  that  it  compresses  the  forefoot  and 
throws  more  weight  upon  it  by  elevating  the  heel.  If  the  arch  is 
depressed  or  becomes  depressed,  or  if  a  bone  m  the  arch  over- 
rides another,  this  compression  causes  the  symptoms. 

Classical  Morton's  neuralgia  is  then  but  one  of  the  s\Taptoms 
of  weakness  of  the  anterior  arch  of  the  foot. 

The  Influence  of  the  Shoe  in  Causing  Disability  and  Pain. — In  the 
etiology  of  pain  and  discomfort  about  the  anterior  arch  one  must 
recognize  the  shoe  not  only  as  the  direct  cause  of  the  pain,  but  also 
as  the  most  important  of  the  predisposing  causes  of  weakness  of 
the  anterior  arch,  of  which  the  pam  is  a  s^Tuptom,  since  it  com- 
presses the  toes,  lifts  them  oft'  the  ground  by  its  "rocker  sole," 
and  thus,  by  preventing  their  normal  function,  thi-ows  additional 
strain  and  pressure  upon  the  arch.    In  fact,  in  a  very  large  propor- 


WEAKNESS  OF   THE  ANTERIOR  METATARSAL  ARCH     737 

tion  of  feet  that  are  supposed  to  be  normal  in  appearance  and  func- 
tional ability,  the  toes  are  habitually  dorsiflexed  in  a  claw-like 
attitude  that  shows  entire  disuse  of  their  function  both  as  to  support 
and  progression.  Women  wear  shoes  with  narrower  soles  and  higher 
heels  than  men,  and  this  seems  the  most  reasonable  explanation 
of  the  fact  that  they  are  more  subject  to  the  affection. 

The  shoe  also  predisposes  to  habitual  elevation  of  the  fifth  meta- 
tarsal bone,  because  this  bone  almost  invariably  overhangs  the 
narrow  sole.  The  fourth  metatarsal  bone  becomes,  therefore,  the 
outer  support  of  the  arch,  and  is  almost  always  found  to  be  on  a 
lower  level  than  the  adjoining  bones.  This  relation,  together  with  a 
laxity  of  muscular  and  ligamentous  support  induced  by  injury  or 
otherwise,  may  account  for  the  location  of  the  pain  at  this  point 
in  the  majority  of  cases.  Although  in  certain  instances  local  neuritis 
may  result  from  repeated  injury,  it  is  a  rather  unusual  complica- 
cation.  Nor  is  it  likely  that  the  peculiar  distribution  of  the  nerves 
at  the  fourth  joint  has  any  direct  influence  on  the  location  of  the 
pain,  for  the  nerve  supply  of  all  the  joints  and  all  the  toes  is  prac- 
tically identical. 

Other  Factors  in  the  Etiology. — Besides  the  general  effect  of  the 
shoe,  and  the  influence  of  an  inherited  predisposition  to  the  affec- 
tion, which  seems  evident  in  certain  cases,  or  of  weakness  or  direct 
injury  of  the  anterior  arch,  one  recognizes  among  the  causes  or 
complications  of  anterior  metatarsalgia  weakness  of  the  longitudinal 
arch,  which  may  be  combined  with  a  depression  of  the  anterior 
arch.  Less  often  the  longitudinal  arch  may  be  exaggerated  in  depth 
and  the  dorsal  flexion  of  the  foot  may  be  limited  by  a  shortened 
tendo-Achillis;  thus  more  pressure  is  brought  upon  the  front  of  the 
foot.  In  these  cases  the  pain  may  be  increased  by  corns  or  calloused 
skin  beneath  the  depressed  bones,  and  in  many  instances  the  dis- 
comfort of  the  depressed  arch  of  the  ordinary  type  is,  in  great  part, 
caused  by  a  sensitive  corn  or  fibroma  at  the  point  of  greatest  depres- 
sion, and  the  patient  may  be  entirely  relieved  by  its  removal. 
(See  Contracted  Foot.) 

Although  the  symptoms  of  anterior  metatarsalgia  may  be 
explained  in  most  instances  by  the  primary  effect  of  improper 
shoes,  by  weakness  and  abnormality  of  the  foot  itself,  and  by  the 
local  sensitiveness  of  the  parts  that  are  continually  subjected  to 
strain,  pressure,  and  injury,  yet  in  some  instances  the  symptoms 
can  be  accounted  for  only  by  local  neuritis;  in  others  they  are 
aggravated  by  gout  or  rheumatism  or  general  debility,  and  as 
has  been  mentioned  in  a  large  proportion  of  the  cases,  the  patients 
are  of  a  distinctly  nervous  type. 

It  may  be  stated,  in  conclusion,  that  anterior  metatarsalgia  in 
its   milder   forms    is    a   very   common  affection   and    one    rarely 
treats   a   patient   who  does   not  know  of  other  cases   similar  to 
his   own. 
47 


738       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

Treatment. — The  most  important  local  treatment  is  to  provide 
the  patient  with  a  suitable  shoe.  This  shoe  must  be  of  proper 
shape  with  a  thick  sole,  so  broad  that  no  lateral  compression  of 
the  toes  is  possible,  with  a  high  arch  and  narrow  counter,  so  that  the 
leather  fitting  closely  about  and  beneath  the  arch  may  hold  the  foot 
securely. 

As  an  immediate  treatment  a  firm  bandage  about  the  meta- 
tarsal region,  as  suggested  by  IMorton,  may  aid  in  supporting  the 
metatarsal  arch,  or,  better,  adhesive-plaster  strapping  may  be 
applied  about  the  entire  metatarsus,  with  the  object  of  compressing 
the  forefoot  somewhat  as  a  tight  glove  compresses  the  hand. 
Beneath  or  slightly  behind  the  affected  joint  or  the  depressed  arch,  a 
pad,  preferably  an  oval  piece  of  sole  leather,  about  one  inch  by 
three-quarters  of  an  inch  in  size  and  one-quarter  in  thickness  with 
be^■elled  edges,  may  be  fixed  to  the  sole  of  the  foot  with  adhesive 
plaster  so  that  depression  of  the  arch  or  overriding  of  the  adjoining 
bones  may  be  prevented.  This  pad,  suggested  by  Poulosson  and 
Goldthwait,  usually  relieves  the  pain,  and  when  the  exact  place 
has  been  ascertained  it  mav  be  fixed  to  the  sole  of  the  shoe. 


Fig.  569. — Exercise  for  the  weakened  metatarsal  arch. 

As  a  rule,  however,  a  metal  support  will  be  found  to  be  more 
comfortable  and  far  more  efficient.  This  may  be  constructed  of 
light  steel  (19  gauge)  upon  a  plaster  cast  of  the  sole  of  the  foot 
suitably  modeled.  The  anterior  extremity  of  the  brace  is  made 
nearly  as  wide  as  the  foot,  and  extends  forward  to  the  extremity 
of  the  sole,  splinting  the  sensitive  metatarsophalangeal  articulations 
thus  differing  entirely  in  its  action  from  pads  or  other  supports  in 
which  the  pressure  is  upon  the  soft  parts  behind  the  joints.  As  a 
rule  a  slight  general  convexity  is  efficient,  but  in  certain  instances 
this  must  be  greatest  behind  the  sensitive  joint  to  relieve  the  pain. 
The  brace  should  also  support  the  longitudinal  arch  to  hold  the  foot 
securely  and  to  relieve  some  of  the  pressure  on  the  metatarsa 


WEAKNESS  OF  THE  ANTERIOR  METATARSAL  ARCH    739 

region.  If  there  is  slight  depression  of  the  longitudinal  arch  it  may 
be  further  corrected  by  raising  the  inner  border  of  the  heel  and  sole 
of  the  shoe;  but  if  it  is  more  pronounced  a  flat-foot  brace  (Fig.  555) 
may  be  employed,  whose  anterior  extremity  is  modified  to  support 
the  metatarsal  arch.  If,  on  the  other  hand,  the  arch  is  exaggerated 
and  if  dorsal  flexion  is  limited,  treatment  with  the  aim  of  relieving 
this  deformity  will  be  necessary,  as  described  under  Contracted 
Foot.  When  the  immediate  symptoms  of  pain  and  local  discomfort 
have  been  relieved,  the  patient  must  endeavor  to  strengthen  the 
natural  supports  of  the  arch  by  proper  functional  use  of  the  foot, 
and  by  regular  exercises  of  the  muscles,  more  especially  by  method- 
ical forced  flexion  of  the  toes,  as  this  motion  elevates  the  anterior 
metatarsal  arch  (Fig.  569).  Massage  of  the  foot  and  forcible  manip- 
ulation of  the  toes  for  the  purpose  of  overcoming  restriction  of 
motion  are  of  special  value. 

If  the  depressed  anterior  arch  is  rigid,  as  in  some  instances,  its 
flexibility  must  be  restored  by  manipulation  or  by  forcible  correc- 
tion under  anesthesia  before  a  brace  can  be  applied.  If  the  symp- 
toms are  very  acute,  and  particularly  if  they  have  followed  direct 
injury,  the  parts  should  be  placed  at  rest  and  the  anterior  arch 
should  be  elevated  and  supported  by  a  properly  applied  plaster 
bandage. 

In  chronic  and  resistant  cases  or  when  conservative  treatment 
cannot  be  applied,  resection  of  the  neck  and  head  of  the  metatarsal 
bone  at  the  seat  of  pain  may  be  performed  as  advocated  by  Morton. 
The  operation  is  very  simple.  An  incision  is  made  over  the  dorsal 
surface  of  the  joint,  and  the  bone  is  divided  by  bone  forceps  or  Gigli 
saw.  The  toe  should  not  be  removed.  After  the  operation  it  slowly 
recedes  between  the  adjoining  metatarsophalangeal  joints,  becom- 
ing somewhat  shorter.  The  operation  is,  as  a  rule,  successful,  but 
in  the  majority  of  cases  it  is  unnecessary. 

The  general  condition  of  the  patient  should,  of  course,  receive 
attention,  and  local  applications,  electricity,  and  the  like  may 
be  of  benefit  in  special  cases. 

Woodrufi^^  described  a  case  of  what  he  called  "incomplete  luxa- 
tion of  the  metatarsophalangeal  articulation,"  in  which  the  symp- 
toms, practically  identical  with  those  of  Morton's  neuralgia,  are 
ascribed  to  an  upward  displacement  of  the  proximal  phalanx  at  the 
fourth  metatarsophalangeal  joint.  These  cases  of  complete  or 
incomplete  luxation  are  not  infrequent  and  unless  the  deformity 
can  be  overcome  by  manipulation  the  head  of  the  depressed  meta- 
tarsal bone  should  be  resected. 

It  may  be  stated  in  this  connection  that  in  the  ordinary  forms  of 
metatarsalgia,  patients  often  refer  the  pain  and  local  sensitiveness 
to  the  anterior  extremity  of  the  metatarsal  bone  rather  than  to  its 

1  New  York  Med.  Rec,  January  18,  1887. 


740       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

lateral  aspect.  Persistent  dorsal  flexion  of  the  toes  that  is  so  com- 
monly associated  with  depression  of  the  arch  by  subjecting  this 
portion  of  the  joint  to  abnormal  pressure,  may  explain  the  location 
of  the  pain. 

A  sensitive  callus  beneath  the  arch  may  require  treatment,  and 
in  certain  cases  its  removal  may  be  the  only  treatment  required 
other  than  an  improved  shoe.  But,  as  a  rule,  the  cause  of  the  callus 
is  habitual  depression  of  one  or  more  of  the  metatarsophalangeal 
articulations,  so  that  cure  can  only  be  assured  by  supporting  the 
arch  and  by  strengthening  its  natural  supports.  If  as  in  certain 
instances  the  depressed  joints  cannot  be  replaced  in  normal  position 
the  head  of  one  or  more  metatarsal  bones  must  be  removed. 

PAINFUL   WARTS. 

Not  infrequenth'  an  area  of  callus  presents  a  series  of  wart-like 
growths  from  the  connective  tissue.  If  these  cannot  be  cured  by 
ordinary  means  complete  removal  of  the  wart-bearing  tissue  may 
be  indicated,  afterward  a  support  must  be  applied  to  assure  relief. 

ACHILLOBURSITIS. 

Synonyms. — Achillodynia,  achillobursitis  anterior,  retrocalcaneo- 
bursitis. 

Under  the  title  of  Achillodynia,  Albert,^  in  1893,  called  par- 
ticular attention  to  an  affection  characterized  by  pain  and  sensitive- 
ness about  the  insertion  of  the  tendo-Achillis, 
symptoms  usually  caused  by  hritation  or  in- 
flammation of  the  small  bursa  lying  between 
the  insertion  of  the  tendon  and  the  bone 
(Fig.  570). 

Etiology. — In  the  acute  cases  the  cause 
of  the  bursitis  often  appears  to  be  a  strain 
of  the  tendon  or  direct  injury,  as  the  symp- 
toms appear  immediately  after  running  or 
jimiping  or  after  a  fall,  sometimes  after  a  long 
walk  or  bicycle  ride.  Seaver^  has  described 
several  cases  in  childhood  in  which  the  sjiiip- 
toms  were  caused  by  injurv  or  displacement 
twien-  thftoidoTchiiiis  ^f  the  posterior  epiphysis  of 'the  os  calcis. 
and  the  OS  caicis.  In  the  subacutc  cases  the  s\Tnptoms  may 

begin  almost  unperceptibly,  so  that  it  may 
be  impossible  to  assign  a  direct  cause  other  than  strain  or  the  pres- 
sure of  the  shoe,  aggravated,  it  may  be,  by  an  exostosis  of  the  os  calcis 
beneath  the  insertion  of  the  tendon  or  by  concretions  T^ithin  the 

1  Wiener  med.  Presse,  Januarj-  8,  1893. 

2  New  York  Med.  Jour.,  Maj-  18,  1912. 


ACHILLOBURSITIS  741 

bursa.  In  many  instances  rheumatism,  gout,  gonorrhea,  or  one  of 
the  infectious  diseases  appear  to  be  associated,  directly  or  indirectly, 
with  the  onset  of  the  symptoms,  or  the  bursa  may  be  secondarily 
involved  in  tuberculous  disease  of  the  os  calcis. 

Symptoms. — In  a  typical  case  pain  is  felt  in  the  back  of  the 
heel  at  the  insertion  of  the  tendon;  the  pain  is  increased  by  use  of 
the  foot,  and  particularly  by  the  attitudes  in  which  the  strain  on 
the  part  is  increased,  as,  for  example,  in  descending  stairs.  There 
is  also  sensitiveness  to  pressure  about  the  back  of  the  heel  on  either 
side  of  the  insertion  of  the  tendon.  In  most  cases  a  slight  swelling, 
often  more  prominent  on  the  inner  than  the  outer  side  of  the  tendon, 
indicates  the  situation  of  the  bursa. 

In  the  chronic  cases  the  enlargement  of  the  bursa  is  very  notice- 
able, and,  in  addition,  the  entire  posterior  aspect  of  the  heel  often 
appears  to  be  thickened.  This  is  due  probably  to  the  secondary 
irritation  about  the  fibrous  expansion  of  the  tendon  and  the  adjoin- 
ing periosteum.  In  many  cases  the  symptoms  are  pronounced; 
pain  is  often  felt  in  the  bottom  of  the  heel  or  it  radiates  up  the  back 
of  the  leg.  The  patient,  unable  to  use  the  power  of  the  calf  muscle, 
everts  the  foot  in  walking,  thus  subjecting  the  arch  to  overstrain, 
so  that  the  symptoms  of  the  weak  foot  are  often  added  to  those  of 
the  original  trouble.  Not  infrequently,  however,  the  two  affections 
may  be  associated  from  the  beginning  in  one  or  the  other  foot.  The 
patient  complains  much  of  stiffness  and  weakness  at  the  ankle  and 
metatarsal  joints.  In  acute  cases,  or  in  acute  exacerbations,  there 
is  usually  burning  and  throbbing  pain  characteristic  of  inflammation, 
but  in  the  subacute  form  the  pain  is  slight,  and  is  troublesome  only 
after  overexertion. 

Pathology. — The  pathological  changes  do  not  differ  from  those 
found  in  and  about  other  bursse  under  similar  conditions.  In  the 
mild  cases  the  lining  membrane  is  simply  congested,  and  the  cavity 
contains  serous  fluid.  In  the  chronic  cases  the  walls  are  much 
thickened,^  the  lining  membrane  is  fringed  and  reduplicated;  the 
contents  are  semisolid,  and  sometimes  calcareous  masses  are  present. 
Similar  changes  are  found,  however,  in  the  bursse  of  apparently 
normal  subjects,  so  that  the  condition  of  the  bursa  may  not  always 
correspond  to  the  character  of  the  symptoms.  Suppuration  of  the 
sac  occasionally  Occurs,  and  it  may  be  the  seat  of  tuberculous  or 
syphilitic  disease.  In  cases  of  long  standing  the  parts  adjoining  the 
bursa,  the  expansion  of  the  tendon,  and  the  periosteum  become 
thickened,  so  that  the  bone  appears  to  be  increased  in  breadth  and 
may  actually  become  so. 

Treatment. — When  once  established  the  affection  is  usually  of  a. 
very  chronic  nature,  as  is  explained  by  the  strain  to  which  the  sensi- 
tive part  is  subjected  by  the  use  of  the  foot.     It  is  therefore  impor- 

1  Rossler:  Dutsch.  Ztschr.  f.  Chir.,  Band  Ixii,  Heft  1  and  3. 


742        DISABILITIES  AXD   DEFORMITIES   OF   THE   FOOT 

tant  to  apply  efficient  treatment  at  the  beginning  of  the  affection  if 
an  opportunity  is  afforded.  Efficient  treatment  imphes  absohite 
rest,  and  in  all  cases  of  any  severity,  particularly  those  of  acute 
onset,  a  well-fitting  plaster  bandage  should  be  applied  to  hold  the 
foot  slightly  inverted  and  at  a  right  angle  to  the  leg.  This  should 
be  worn  until  all  symptoms  have  subsided.  In  very  mild  cases, 
following  immediately  on  a  strain  or  overuse,  simple  rest  with  the 
application  of  heat,  massage,  and  pressure  may  be  efficient.  And  in 
the  subacute  cases  the  s^^nptoms  may  be  relieved  by  the  application 
of  a  long,  broad  band  of  adhesive  plaster,  from  the  toes  over  the  back  of 
the  heel  to  the  upper  third  of  the  calf,  the  foot  being  slightly  plantar 
flexed.  This  is  firmly  fixed  by  narrow  strips  of  plaster  about  the  meta- 
tarsus, the  heel,  and  the  calf.  By  this  means  pressure  is  exerted 
upon  the  bursa,  and  much  of  the  strain  is  removed  from  the  tendon. 

In  persistent  cases  a  brace  may  be  used  with  advantage  for  the 
purpose  of  preventing  strain  upon  the  tendon.  Two  lateral  uprights 
vdih  a  caK  band  and  padded  strap  that  crosses  the  upper  third  of 
the  leg  are  attached  to  the  shoe,  provided  with  a  stop  joint  at  the 
ankle  as  used  in  the  treatment  of  paralytic  calcaneus  to  prevent 
dorsal  flexion.  (See  Talipes.)  As  the  patient  is  usually  sensitive 
to  jar,  the  heel  of  the  shoe  should  be  replaced  by  one  of  thick  rubber. 
In  connection  with  the  brace  the  stimulation  of  the  cautery  and  the 
pressure  of  the  adhesive-plaster  strapping  seem  to  hasten  the  absorp- 
tion of  the  effusion  in  and  about  the  bursa.  If  weakness  or  depres- 
sion of  the  arch  is  present,  as  a  result  of  the  disability  or  combined 
with  it,  a  foot  plate  should  be  applied,  and  general  affections,  with 
which  the  disability  is  sometimes  associated,  should,  of  coiu'se, 
receive  attention. 

Operative  Treatment. — In  persistent  cases,  in  which  the  symptoms 
are  not  relieved  by  treatment,  the  enlarged  bursa  should  be  removed 
by  an  incision  on  the  inner  side  of  the  tendon,  as  the  swelling  is 
usually  most  prominent  here.  A  plaster  bandage  is  then  applied 
and  is  continued  until  the  symptoms  have  subsided.  If  the  case  is  a 
chi'onic  one,  it  may  be  advisable  to  divide  the  tendo-Achillis  in  order 
to  completely  remove  for  a  time  the  strain  upon  the  sensitive  part. 
A  brace  of  the  character  already  described  may  be  used  with  advan- 
tage for  a  time  after  the  plaster  support  has  been  removed.  Operative 
treatment  is,  of  com'se,  indicated  in  acute  suppurative  inflammation, 
in  tuberculous  disease,  or  if  an  exostosis  beneath  the  bursa  or  concre- 
tions within  the  sac  are  present,  as  shown  by  an  .r-ray  negative. 

Achillobursitis  Posterior. — ^Tenderness,  pain,  and  swelling  at  the 
back  of  the  heel  may  be  due  to  inflammation  of  the  small  superficial 
biu"sa  that  lies  between  the  tendon  and  the  skin.  The  cause  is 
usually  injury  or  the  pressm-e  of  the  shoe.  The  symptoms  resemble 
somewhat  those  of  achillobiu-sitis  anterior,  but  the  swelling  is  more 
superficial,  and  the  pain  is  caused  by  direct  pressure  rather  than  by 
tension  on  the  tendo-Achillis.     In  the  ordinarv  case  removal  of  the 


PAINFUL  HEEL  743 

pressure  will  at  once  relieve  the  sjTQptoms,  but  if  the  discomfort 
is  considerable  a  plaster  bandage  may  be  worn  for  a  week  or  more. 

Sensitive  points  at  the  back  of  the  heel  are  usually  caused  by  the 
pressure  of  the  shoe.  In  rare  instances  prominent  points  or  exos- 
toses of  the  OS  calcis  are  present,  that  may  require  special  protection 
or  removal. 

STRAIN  OF  THE  TENDO-ACHILLIS. 

Not  infrequently,  and  usually  as  the  result  of  strain  or  overuse  of 
the  foot,*  patients  complain  of  symptoms  similar  to  those  of  achillo- 
bursitis,  but  on  examination  one  finds  that  the  pain  and  sensitiveness 
are  referred  to  the  tendon  itself  which  is  often  enlarged  (peritendin- 
itis). The  sensitive  area  may  be  as  high  up  as  the  junction  of  the 
tendon  with  the  muscle,  but  usually  the  midpoint  of  the  tendon 
is  most  painful. 

The  cause  in  some  cases  may  be  a  direct  strain  of  the  tendon  or  of 
the  muscular  fibres  near  its  origin,  or  inflammation  of  its  fibrous 
covering  due  probably  to  the  same  cause.  The  treatment  is  similar 
to  that  of  the  milder  type  of  achillobursitis,  by  the  adhesive-plaster 
strapping,  by  rest,  and  later  by  massage.    Recovery  is  usually  rapid.^ 

PAINFUL  HEEL— CALCANEOBURSITIS. 

Pain  referred  to  the  bottom  of  the  heel  and  sensitiveness  to  pres- 
sure on  standing  are  common  symptoms  of  the  weak  or  fiat-foot. 
Pain  at  this  point  may  be  one  of  the  symptoms  of  achillobursitis 
also.  In  rare  instances  the  painful  point  is  clearly  localized,  and  is 
confined  to  a  small  area  in  the  neighborhood  of  the  inner  tuber- 
osity of  the  OS  calcis.  The  cause  of  the  symptoms  in  such  cases 
may  be  an  inflamed  bursa  lying  between  the  periosteum  and  the  fatty 
tissue  of  the  heel.  Painful  heels  are  a  not  uncommon  complication 
of  gonorrhea,  and  in  cases  of  long  standing  the  local  inflammation 
apparently  beginning  in  the  musculoperiosteal  attachment  of  the 
flexor  brevis  digitorum  may  result  in  ossification  (exostosis).  Pro- 
jections of  bone  in  this  locality  are  often  seen  in  a:-ray  pictures  of 
normal  feet  and  in  many  instances  a  weakened  or  depressed  arch  is 
the  exciting  cause  of  pain  which  an  exostosis  merely  aggravates.^ 

More  general  pain  and  sensitiveness  referred  to  the  heel  are  often 
the  result  of  direct  pressure  and  bruising  of  the  tissues  incidental 
to  overuse  of  the  feet. 

Treatment. — Treatment  must  be  directed  to  the  condition  of 
which  the  pain  is  a  symptom,  and,  as  has  been  stated,  it  is  most 
often  one  of  the  symptoms  of  the  weak  or  broken-down  arch.     If 

1  Rupture  of  the  tendo-Achillis,  complete  or  partial,  is  occasionally  seen.  As  a 
rule  the  diagnosis  is  not  made  at  the  time  of  the  injury.  If  the  rupture  is  complete, 
operative  repair  is  indicated.  Rupture  of  the  plantaris  is  more  common  The  sen- 
sation is  of  a  sharp  blow  on  the  calf.  There  is  often  swelling  of  the  calf  and 
extensive  discoloration  of  the  skin.  Rest,  strapping  and  bandaging  usually  relieve 
the  symptoms 

^  Baer:  Surg.,  Gynec.  and  Obst.,  July  2,  1906. 


744       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

the  sensitive  point  is  localized,  and  if  the  pain  is  increased  by  jars, 
a  thick  rubber  heel  combined  with  an  inner  sole,  so  cut  out  as  to 
remove  the  direct  pressure  on  the  sensitive  point,  will  often  relieve 
the  sjTnptoms.  In  persistent  cases,  in  which  the  sensitive  point  is 
distinctly  localized,  operative  intervention  for  the  removal  of  the 
biu-sa  or  exostosis  is  indicated. 

Sensitiveness  due  to  direct  contusion,  or  bruising  of  the  tissues 
caused  by  overuse,  must  be  treated  by  rest  and  by  change  of  occu- 
pation, unless  reduction  of  the  body  weight  or  improvement  in 
attitudes  and  local  support  relieve  the  SA^mptoms. 

PLANTAR  NEURALGIA. 

Synonym.— Plantalgia . 

Pain  referred  to  the  sole  of  the  foot  and  sensitiveness  to  pressure 
on  the  plantar  fascia  are  usually  symptomatic  of  the  contracted  foot 
(cavus) ;  less  often  such  symptoms  accompany  the  weak  or  broken- 
down  arch. 

Pain,  tenderness,  and  thickening  of  the  fascia  sometimes  follow 
injury  (rupture  of  the  fascia),^  and  a  similar  condition  has  been 
described  by  Franke  as  one  of  the  sequelae  of  influenza.^  It  may  be 
present,  also,  in  patients  who  suffer  from  gout  or  rheumatism. 

Treatment. — Pain  in  the  sole  of  the  foot,  symptomatic  of  the 
contracted  or  of  the  weak  foot,  may  be  relieved  by  the  treatment 
of  the  conditions  of  which  it  is  a  symptom.  In  the  rare  instances  in 
which  the  fascia  is  itself  injured,  or  diseased,  local  rest,  as  afforded 
by  the  plaster  bandage,  is  indicated  until  the  acute  symptoms  have 
subsided. 

VASOMOTOR  TROPHIC  NEUROSES. 

Under  this  title  may  be  included  angioneurotic  edema,  acropares- 
thesia, erji:hromelalgia,  Raynaud's  disease,  and  the  like  affections, 
functional  rather  than  organic  in  character,  and  due  apparently 
to  disturbance  of  the  s\Tnpathetic  system. 

Angioneurotic  Edema. — Angioneurotic  edema  is  characterized  by 
a  sudden  localized  swelling  of  the  tissues,  waxy  or  sometimes  of  a 
dark  red  color.  Usually  it  does  not  pit  on  pressure.  It  is  not 
painful  and  it  disappears  in  a  few  days. 

Acroparesthesia. — Acroparesthesia  is  a  sensation  of  numbness  and 
weakness  in  one  or  both  of  the  upper  or  lower  extremities  usually 
of  a  passing  character. 

Erythromelalgia. — Erythromelalgia^  is  characterized  by  pain  in  a 
defined  area  usually  of  the  legs  and  feet,  attended  by  heat,  redness, 
and  often  by  swelling,  lasting  a  few  hours.  It  has  a  tendency  to 
recur  at  intervals. 

1  Lederhose:  Verhandl.  d.  Deutsch.  Gesellsch.  f.  Chir.,  XXIII.  Kong.,  1894. 

2  Arch.  f.  klin.  Chir.,  1895,  xlix. 

3  Weir  Mitchell,  PhHa.  Med.  Times,  1872. 


DYSBASIA  ANGIOSCLEROTICA  745 

Raynaud's  Disease. — Raynaud's  disease^  is  a  local  ischemia  caused 
apparently  by  spasmodic  contraction  of  the  arterial  distribution, 
the  "dead  finger"  being  the  most  familiar  example.  It  may  involve 
any  part,  even  the  nose  and  ears.  The  affected  part  is  white  or 
cyanotic  or  red  in  color,  with  a  lowering  of  the  temperature,  although 
occasionally  heat  and  pain  are  present.  In  the  mild  forms  recovery 
is  spontaneous,  in  others,  local  gangrene  may  follow. 

DYSBASIA  ANGIOSCLEROTICA  AND  THROMBO-ANGIITIS 
OBLITERANS. 

Dysbasia  Angiosclerotica^  {Intermittent  Limp). — The  name 
implies  a  sclerotic  change  in  the  bloodvessels  that  lessens  their 
capacity.  Consequently  the  blood  supply  is  insufficient  for  active 
use.  The  patient  after  walking  for  a  time,  complains  of  pain  in  the 
calf  of  the  affected  leg,  "cramps,"  limps  and  must  rest  for  a  time 
before  resuming  activity. 

This  affection  in  a  mild  form  is  not  uncommon  in  elderly  subjects 
and  is  relieved  usually  by  accommodating  the  activities  to  the  dimin- 
ished nutrition. 

Thrombo-angiitis  Obliterans.^ — This  disease  is  usually  closely 
allied  in  the  symptoms  to  the  preceding,  but  of  a  much  more  serious 
character.  It  affects  young  or  middle-aged  adult  males,  usually 
Russian  Jews.  It  is  a  thrombotic  process  involving  the  veins  as  well 
as  the  arteries,  apparently  of  an  inflammatory  nature,  chronic 
and  irregular  in  its  character,  sometimes  intermittent  as  regards 
symptoms,  in  other  instances  progressing  to  the  extent  of  causing 
necrosis  in  a  year  or  less.  The  symptoms  are  pain  on  walking 
rather  than  standing,  cramps  in  the  limbs,  numbness,  and  pain  at 
night  when  the  feet  are  on  the  horizontal  plane.  The  disease  is 
practically  confined  to  the  lower  limbs  below  the  knees,  and  in  the 
beginning  is  usually  unilateral. 

The  diagnosis  is  easily  made  from  the  symptoms  and  from  the 
appearance  of  the  foot  which  is  cyanotic  or  of  a  dusky  red  color  when 
dependent,  the  pulsation  of  the  arteries  being  weak  or  imperceptible. 
In  typical  cases  the  pain  and  disability  are  progressive.  Dry 
gangrene  follows  and  amputation  is  required.  The  etiology  is 
obscure.  Excessive  smoking  has  by  some  been  considered  a  factor. 
The  treatment  is  unsatisfactory.  It  w^ould  seem  that  prolonged 
rest  at  an  early  stage  of  the  process  might  be  the  most  efficacious 
remedy  for  an  inflammatory  process.  In  the  advanced  stage  hypo- 
dermoclysis  with  Ringer's  solution,  500  c.c.  every  second  or  third 
day,  has  been  employed  with  apparent  relief  of  pain.  Bier's  treat- 
ment and  the  Klapp  suction  appliances  have  been  used  to  induce 
venous  congestion. 

1  Arch.  Gen.  de  Med.,  1874.  2  Charcot:  Gaz.  de  Paris,  1850. 

3  Leo  Buerger:  Am.  Jour.  Med.  Sc,  January,  1910. 


746       DISABILITIES  AXD  DEFORMITIES  OF   THE  FOOT 

Ligation  of  the  femoral  vein  or  anastomosis  of  the  femoral 
artery  and  vein  with  the  aim  of  increasing  the  blood  supply  have 
apparently  been  of  temporary  benefit. 


HALLUX  RIGroUS. 

Synonyms. — Hallux  flexus,  painful  great  toe. 
HalliLx  rigidus  is  a  painful  affection  of  the  great  toe-joint,  char- 
acterized by  restriction  of  motion,  particularly  of  the  range  of  dorsal 
flexion.  In  advanced  cases  the  first  phalanx  may  be  slightly  plantar 
flexed,  together  with  its  metatarsal  bone;  hence  the  name  hallux 
flexus,  applied  by  Davies-Colley,  who  first  described  the  affection. 

The  restriction  of  motion  may  be  complete,  as  implied  by  the 
term  rigidus;  the  joint   appears  unduly  prominent  or  enlarged, 
usually   slightly   congested,    and   pressure  or 
forced  movement  causes  pain. 

The  symptoms  of  which  the  patient  com- 
plains are  a  burning  or  tlii'obbing  pain  in  the 
joint,  increased  by  standing,  and  particularly 
by  walking,  because  of  the  enforced  movement 
of  the  stiff'  and  painful  articulation.  There 
are  many  cases  in  which  there  is  no  actual 
deformity  of  the  joint  or  other  noticeable 
change ;  the  restriction  of  motion  is  much  less, 
and  the  s\Tnptoms  are  correspondingly  slight. 
Etiology. — Typical  hallux  rigidus  is  most 
common  in  adolescence,  and  it  is  very  often 
associated  with  the  weak  or  broken-down  foot. 
In  such  cases  the  toe  is  forced  into  the 
narrow  part  of  the  shoe,  and  is  thus  subjected 
to  lateral  and  to  longitudinal  pressure,  as  well 
as  to  the  additional  strain  that  the  attitude, 
characteristic  of  the  weak  foot,  throws  upon  it.  In  some  cases  the 
habitual  plantar  flexion  of  the  toe  may  be  the  result  of  an  instinctive 
effort  to  support  the  weak  arch  (hammer-toe  flat-foot).  In  other 
instances  hallux  rigidus  is  caused  directly  by  traumatism,  as  by 
stubbing  the  toe,  by  kicking  a  hard  object,  or,  by  other  form  of 
strain  or  injury.  The  affection  appears  to  be,  primarily,  a  form  of 
periarthi'itis.  The  restriction  of  motion  is  in  part  due  to  muscular 
spasm,  and  in  part  to  the  irritative  and  accommodati\-e  changes  in 
the  ligaments  and  tendons.  In  more  advanced  cases  changes  in  the 
cartilage  and  shape  of  the  articulating  surfaces,  due  to  disuse  of 
function  and  to  pressure  and  friction,  may  be  present. 

Treatment. — If  the  stiff  and  painful  joint  is  not  associated  with 
a  weak  arch,  it  may  be  relieved  by  providing  the  patient  with  a 
proper  shoe  which  exerts  no  pressure  on  the  sensiti^'e  part.  ^Motion 
of  the  joint  may  be  lessened  by  increasing  the  thickness  of  the  sole, 


Fig.  571.— Thedotted 
outline  shows  the  shape 
of  the  steel  splint  that 
may  be  inserted  in  the 
sole  of  the  shoe  for  hal- 
lux rigidus. 


HALlUX  RIGIDUS 


747 


or,  if  necessary,  it  may  be  entirely  restricted  by  the  insertion  of  a 
brace  of  tempered  steel  between  the  two  layers  of  the  sole,  as  shown 
in  the  diagram  or  by  a  sole  plate  within  the  shoe.  If,  as  in  some 
instances,  the  flexed  and  painful  toe  is  associated  with  rigid  flat- 
foot,  both  deformities  may  be  overcorrected,  under  anesthesia, 
and  retained  in  proper  position  by  a  plaster  bandage,  as  a  prelimi- 
nary treatment. 

If  the  milder  type  of  painful  joint  is  associated  with  the  ordinary 
weak  foot,  the  treatment  of  the  latter  condition  will  usually  relieve 
the  symptoms.  In  this  class,  particularly  among  the  poorer 
patients,  the  shoe  may  be  raised  on  the  inner  side  and  the  sole 


Fig.  572.- 


-Hallux  rigidus  and  fiat-foot,  showing  tlie  persistent  flexion  of  tiie  toe  on 
tlie  metatarsal  bone. 


stiffened  by  means  of  the  wedge-shaped  sole,  as  already  described  in 
the  treatment  of  the  weak  and  flat-foot.  If  motion  is  restricted, 
and  if  the  exciting  causes  of  the  disability  are  removed,  relief  of  the 
symptoms  is  usually  immediate.  In  the  chronic  cases,  in  which  the 
pathological  changes  are  more  advanced,  excision  of  the  head  of  the 
metatarsal  bone  may  be  necessary. 

Painful  Great  Toe-joint  in  Older  Subjects. — A  similar  condition 
of  the  joint  is  sometimes  found  in  older  subjects.  In  many 
instances  the  foot  is  well-formed,  and  the  restriction  of  motion  in 
the  joint  is  very  slight;  yet  forced  dorsal  flexion  causes  pain,  and 
long  standing  or  walking  induces  discomfort,  particularly  a  dull 
ache  in  the]  joint  and  sharp  neuralgic  pain  referred  to  the  terminal 


748        DISABILITIES  AXD   DEFORMITIES   OF    THE  FOOT 

phalanx.  In  some  cases  the  onset  of  the  symptoms  may  be 
ascribed  to  a  long  walk  or  "mountain  climb,"  in  others  to 
wearing  tight  shoes,  and  in  some  instances  no  definite  cause  can  be 
assigned  by  the  patient.  In  cases  of  this  type  the  symptoms  are 
often  supposed  to  be  evidences  of  gout  or  rheumatism  and  in  certain 
instances  there  is  a  distinct  h^-pertrophic  change  corresponding  to 
Heberden's  nodes  on  the  fingers.  Although  the  discomfort  may  be 
aggravated  by  constitutional  diseases,  still  no  relief  can  be  obtained 
by  medication  unless  it  is  combined  with  the  local  treatment  that 
has  been  described  in  the  preceding  section.  The  relief  often 
aft'orded  by  such  treatment  alone  proves  that  the  aftection  is  local 
in  its  character  (Fig.  572).  In  those  cases  in  which  the  joint  is 
enlarged  by  actual  overgroT^i;h  of  cartilage  or  bone  with  discomfort 
on  movement  and  pressure,  operative  treatment  is  indicated.     An 


Fig.  573. — Local  arthritis  deformans  of  the  great  toe-joint. 

incision  is  made  from  the  centre  of  the  dorsal  siuface  of  the  joint 
doTMiward  and  inward  to  the  base  of  the  phalanx.  A  wide  flap  of 
capsule  is  separated  from  the  phalanx  and  turned  backward, 
exposing  the  joint.  The  hApertrophied  extremity  of  the  metatarsal 
bone  is  then  removed  with  a  thin  chisel,  the  flap  of  capsule  is  tiuned 
in  between  the  bones  and  the  wound  is  closed.  If  on  examination 
the  joint  appears  to  be  in  fair  condition  the  marginal  projections 
may  be  removed,  thus  reducing  the  head  of  the  metatarsal  bone  to 
less  than  the  normal  size  and  preserving  the  articulation. 

As  has  been  mentioned,  pain  referred  to  this  joint  is  a  common 
SATnptom  of  the  weak  foot  and  of  the  contracted  foot  as  well.  It  is 
also  caused  by  simple  pressiu-e  on  the  joint,  and  by  the  use  of 
improper  shoes  which  force  the  toes  into  the  abducted  position. 

In  rare  instances  pain  directly  beneath  the  great  toe  and  sensi- 
tiveness to  pressure  about  the  sesamoid  bones  seem  to  indicate  an 


HALLUX   VARUS  749 

inflammation  of  the  tendon  sheath  or  local  periarthritis.  If  the 
discomfort  is  persistent  the  sesamoid  bones  may  be  removed.  As  a 
rule,  however,  such  symptoms  occur  only  in  combination  with  pain 
or  deformity  of  the  great  toe-joint. 

HALLUX  VARUS. 

Adduction  of  the  great  toe  is  not  infrequent  in  infancy,  and  it  may 
be  associated  with  a  slight  degree  of  varus  deformity  (Fig.  574). 
The  pectiliarity  attracts  the  mother's  attention  because  of  the 
difficulty  of  drawing  on  the  socks.  In  many  instances  the  adductor 
muscles  seem  abnormally  developed,  and  the  toe  appears  to  be 
somewhat  prehensile  in  its  movements. 


Fig.  574.— Simple  congenital  varus,  adduction  without  inversion — a  form  of  pigeon- 
toe. 

Treatment. — The  abnormal  mobility  may  be  checked  by  enclos- 
ing the  toes  with  a  narrow  strip  of  adhesive  plaster;  in  any  event 
the  ordinary  shoe  may  be  depended  upon  to  correct  any  residual 
deformity  of  this  character.  If  the  adducted  toe  is  combined  with 
varus,  the  deformity  must  be  corrected  in  the  ordinary  manner. 
(See  Talipes.) 

Pigeon-toe. — Congenital  hallux  varus  forms  one  variety  of  what 
is  known  as  pigeon-toe  or  the  habitual  turning  in  of  the  feet  in 
walking.  The  inward  rotation  may  be  due  also  to  bow-legs,  or  it 
may  be  an  effect  of  congenital  talipes  that  persists  after  the  cure  of 
the  deformity,  or  of  the  exceptional  variety  of  coxa  vara  in  which  the 
depressed  necks  of  the  femora  are  turned  forward.  In  most 
instances,  however,  pigeon-toe  in  childhood  is  symptomatic  of  weak- 
ness either  of  the  arch  of  the  foot  or  of  the  knees  (genu  valgum) . 


750       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


In  such  cases  it  is  a  conservative  effort  of  nature  to  check  further 
deformity,  and  it  needs  no  treatment  other  than  that  which  may  be 
appHed  to  the  weakness  or  deformity  of  which  it  is  a  s^Tnptom. 

In  the  exceptional  cases,  in  which  the  posture  is  not  symptomatic 
of  weakness  or  the  effect  of  deformity,  the  sole  of  the  shoe  may  be 
raised  slightly  on  the  outer  border.  This  will  correct  the  attitude  in 
the  milder  type,  if  combined  with  instruction  and  training.  In  rare  in- 
stances the  in-toeing  seems  to  be  caused 
by  limitation  of  the  range  of  outward 
rotation  at  the  hip-joints,  a  restriction 
that  must  be  overcome  by  systematic 
stretching  of  the  contracted  parts.  In 
these  and  in  the  more  obstinate  cases 
of  the  simple  type  apparatus  may  be 
applied,  similar  to  that  used  in  the 
after-treatment  of  congenital  club- 
foot, to  hold  the  feet  in  the  proper  at- 
titude (Fig.  575) .  It  must  be  borne  in 
mind  that  the  proper  attitude  of  the 
feet  is  one  of  parallelism,  not  of  outward 
rotation,  and  that  slight  pigeon-toe  will, 
as  a  rule,  correct  itself  as  the  child 
grows  older. 


Fig.  575. — An  appliance  con- 
structed of  leather  bands  and 
elastic  webbing  for  the  correction 
of  in-toeing.  Name  of  the  inven- 
tor unknown. 


Fig.  576. — Metatarsus  varus. 


METATARSUS  VARUS. 

This  is  a  deformity  in  which  the  metatarsus  is  adducted  on  the 
tarsal  bones.     It  may  be  congenital,  as  in  talipes  varus,  in  slight 


HALLUX   VALGUS  751 

degree  it  may  be  a  compensatory  effect  of  valgus  deformity  or 
knock-knee  and  it  may  be  an  accompaniment  of  valgus  deformity 
of  the  posterior  division  of  the  foot.  The  treatment,  if  the  deform- 
ity is  well  marked,  corresponds  to  that  of  congenital  varus  (Fig.  576). 

HALLUX  VALGUS. 

Hallux  valgus  is  a  deformity  in  which  the  great  toe  is  turned  out- 
ward to  an  exaggerated  degree.  Outward  deviation  of  the  toe 
induced  by  the  shoe  is  so  common  that  it  is  not  recognized  as  a 
deformity,  at  least  from  the  popular  stand-point,  unless  the  joint 
appears  to  be  much  "enlarged,"  forming  a  so-called  bunion. 

Hallux  valgus  is  practically  a  subluxation.  In  well-marked  cases 
the  metatarsal  bone  is  adducted  or  turned  inward,  so  that  an  abnor- 
mal interval  separates  its  head  from  its  fellows,  while  the  phalanx  is 
displaced  outward  and  articulates  only  with  the  outer  condyle. 
The  angle  thus  formed,  or,  more  properly,  the  inner  condyle  of  the 
adducted  metatarsal  bone,  makes  the  prominent  or  "  outgrown" 
joint  (Fig.  590).  This  projects  sharply  beneath  the  skin,  and  being 
exposed  to  injury  and  to  the  pressure  of  the  shoe,  a  bursa  often 
develops  beneath  the  skin,  while  a  corn  or  callus  forms  on  its  super- 
ficial surface.  The  projecting  bone,  the  bursa  and  the  thickened 
tissues  make  up  the  typical  bunion. 

In  many  instances  the  other  toes  are  displaced  outward,  all  the 
metatarsal  bones  being  somewhat  adducted,  and  in  extreme  cases 
the  great  toe  may  be  rotated  on  its  long  axis  and  lie  above  or  beneath 
its  fellows.  As  a  secondary  effect  the  forefoot  is  broadened  and  the 
metatarsal  arch  is  depressed.  The  deformity  is  often  combined  with 
weak  foot,  although  in  many  instances  the  arch  is  of  normal  height. 

Etiology. — The  deformity  is  the  direct  effect  of  shoes  that  are 
too  narrow,  too  pointed,  and  in  some  instances  too  short  for  the 
foot,  so  that  the  great  toe  is  subjected  to  lateral  and  longitudinal 
pressure.  The  deforming  effect  of  the  shoe  is  increased  if  the  arch 
is  weak,  so  that  the  toe  is  forced  forward  into  the  narrower  part  of 
the  shoe  when  the  foot  is  in  use.  The  deformity  may  be  increased 
or  induced  by  injury  or  by  the  changes  that  follow  gout,  rheuma- 
tism, infectious  arthritis,  diseases  of  the  nervous  system  and  the  like, 
and  in  rare  instances  the  distortion  may  be  the  direct  result  of  such 
diseases;  but  all  other  factors  are  of  slight  importance  when  com- 
pared to  the  influence  of  the  ordinary  shoe.  The  deformity  begins 
at  a  very  early  age;  it  advances  more  rapidly  during  adolescence, 
but  the  symptoms  do  not  often  become  troublesome  until  later  years. 
Both  toes  are  affected,  as  a  rule,  although  the  deformity  and  its 
accompanying  symptoms  are  usually  more  marked  on  one  side. 

Pathology. — The  pathological  changes  are  such  as  usually  follow 
deformity,  disuse  of  function,  and  injury.  The  cartilage  on  the 
exposed  condyle  atrophies,  the  sesamoid  bones,  together  with  the 


752       DISABILITIES  AXD  DEFORMITIES  OF   THE  FOOT 

tendon,  are  displaced  outward,  the  tissues  on  the  outer  side  undergo 
accommodative  shortening,  while  those  on  the  inner  side  are  cor- 
respondingly lengthened  and  attenuated.  The  surface  of  the  bone 
beneath  the  irritated  periosteum  is  often  roughened  and  irregular, 
and  exostoses  may  form  about  the  condyle,  and  thus  aggravate  the 
effects  of  the  lateral  pressure. 

Symptoms. — As  has  been  stated,  the  slighter  grades  of  deformity 
are  not  recognized  as  such,  and  it  is  usually  because  of  the  pain  due 
to  the  irritated  corn  or  bursa,  and  incidently  because  of  the  out- 
grown joint,  that  the  patients  apply  for  treatment. 

Treatment. — The  symptoms  in  the  ordinary  cases  may  be 
relieved  by  providing  a  proper  shoe,  by  which  pressure  on  the  joint 
is  completely  removed  (Figs.  544  and  587).  The  shank  should  be 
narrow  so  that  the  upper  leather  may  hold  the  arch  securely.  The 
sole  should  be  strong,  and  it  should  be  slightly  thicker  along  the 
inner  border,  so  that  the  sensitive  joint  may  be  inclined  away  from 
the  upper  leather.  In  cases  in  which  the  deformity  is  slight  the  use 
of  a  suitable  shoe  that  allows  space  for  an  improved  position  of  the 
great  toe,  combined  with  methodical  manual  correction  of  the 
deformity  and  exercise  of  the  disused  muscles  while  the  toe  is  guided 
in  the  proper  direction  by.  the  fingers,  will  relieve  the  sjTuptoms 
promptly  and  lessen  the  distortion.  If  the  longitudinal  or  the  meta- 
tarsal arches  are  depressed  they  should  be  properly  supported 
(Figs.  552  and  555).  ScA'eral  forms  of  corrective  braces  have  been 
devised,  to  be  worn  during  the  day,  a  digitated  stocking  and  special 
shoe  being,  of  course,  necessary. 

A  simple  device  for  holding  the  toe  in  an  improved  position  is 
the  Holden  toe-post,  recommended  by  Walsham  and  Hughes. 
This  is  a  thin  piece  of  metal  so  fixed  in  the  front  and  inner  side 
of  the  sole  of  the  shoe  that  it  separates  the  first  and  second  toes 
from  one  another  and  holds  the  former  in  an  improved  position. 
It,  of  course,  necessitates  a  special  shoe  and  a  special  shoemaker 
to  fit  it  in  its  proper  place. 

Sampson^  makes  the  toe-post  of  tin  and  places  it  in  a  cardboard 
imier  sole,  as  illustrated  in  the  diagrams  (Figs.  577  to  580). 

The  use  of  a  splint  at  night  is  also  of  some  service.  For  this 
purpose  a  piece  of  celluloid  about  one-eighth  inch  in  thickness, 
one  inch  in  width,  and  about  six  inches  in  length  may  be  used. 
This,  having  been  moulded  to  the  proper  contour  by  placing  it  in 
hot  water,  is  secured  by  tapes  to  the  inner  side  of  the  toe  and  foot. 

It  may  be  stated  that  in  the  class  of  cases  that  can  be  success- 
fully treated  by  mechanical  correction  very  few  patients  will  be 
found  who  are  suflBciently  interested  in  the  cme  of  the  deformity 
to  submit  to  the  slight  discomfort  that  the  wearing  of  even  a  care- 
fully adjusted  brace  entails. 

1  Johns  Hopkins  Bulletin,   Januarj-,    1902. 


HALLUX   VALGUS 


753 


Operative  Treatment. — In  cases  in  which  the  deformity  is  of  long 
standing,  and  in  which  the  projecting  condyle  or  the.  exostoses 
make  protection  of  the  sensitive  joint  difficult,  an  operation  is 
indicated.    The  primary  object  of  the  operation  is  to  remove  the 


je 


H 


D 


B 


Fig.  577. — Making  the  pattern  for  a  toe-post.  A  heavy  piece  of  paper  folded  once 
along  the  line  AB,  ABE  and  BCF  are  cut  away,  leaving  the  tongue  ADCB.  AD 
should  equal  the  depth  of  the  shoe  at  that  point,  and  AB  should  be  as  wide  as  the 
length  of  the  sht  in  the  cardboard  inner  sole.  The  tongue  is  inserted  in  the  slit,  and 
the  bases  folded  back  and  cut  away  to  conform  to  the  front  of  the  inner  sole.  When 
removed  and  straightened  out  this  forms  the  pattern.  Fig.  578. 


^ 


A 


B 


D 


T) 


'-^C 


H 


F  F 

Fig.  578. — Pattern  of  paper  from  which  the  tin  is  cut.  The  edges  DD  and  CC  are 
to  be  turned  in.  Tin  is  folded  along  the  dotted  hnes  AB—DC  and  DC  forming  the 
toe-post  in  Fig.  579. 


Fig.  579.— Shows  the  toe-post  ready  to  be  inserted  into  the  cardboard  inner  sole. 
Rough  points  on  the  upper  and  under  surfaces  of  the  base,  which  are  made  by  punch- 
ing holes  with  an  awl,  hold  the  toe-post  to  both  the  inner  sole  of  the  shoe  and  the  card- 
board inner  sole. 


Fig.  580. 


-Cardboard  inner  sole  with  toe-post  and  foot  adductor  attached. 
(Sampson.) 


projecting  bone.  This  may  be  accomplished  by  a  slightly  curved 
incision  about  the  inner  aspect  of  the  condyle,  the  centre  being 
below  the  joint,  so  that  the  scar  will  not  be  subjected  to  pressure. 
The  flap  of  skin  is  raised,  the  capsule  is  split  and  separated,  exposing 
the  hea,d  of  the  metatarsal  bone.  With  a  sharp  chisel  the  disused 
48    '  ' 


754       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

half  of  the  articulating  extremity  and  adjoining  shaft  of  the  meta- 
tarsal bone  is  split  off  in  the  axis  of  the  shaft,  together  with  all  its 
projections,  so  that  the  entire  external  surface  is  flat  and  smooth. 
Contracted  tissues  that  resist  a  corrected  position  of  the  toe  are 
stretched  or  divided,  and  the  capsule  and  skin  having  been  closed 
with  catgut,  a  plaster  bandage  is  applied  about  the  foot  and  toe. 
This  may  be  worn  with  advantage  for  several  weeks.  The  after- 
treatment  consists  in  the  use  of  a  proper  shoe  and  daily  manual 
adduction  of  the  toe,  in  order  to  retain  the  improved  position. 

Resection  with  chisel  or  Gigli  saw  of  the  head  of  the  metatarsal 
bone  is  the  most  effective  operation  if  the  deformity  is  extreme. 
It  should  not  be  employed  in  ordinary  cases,  as  the  removal  of  the 
head  of  the  bone  lessens  the  direct  support  of  the  inner  border  of 
the  foot  and  limits  effective  flexion  of  the  toe.  In  cases  of  resection 
the  bursa  may  be  interposed  between  the  extremity  of  the  meta- 
tarsal bone  and  the  phalanx  to  lessen  the  danger  of  anchylosis  as 
suggested  by  i\Iayo. 

As  has  been  stated,  hallux  valgus  is  often  combined  with  the  weak 
or  broken-do^Ti  arch  and  practically  always  by  a  depression  of  the 
metatarsal  arch.  In  such  cases  the  foot  should  be  supported  by  a 
properly  fltted  brace.  This  is  of  special  importance  after  treatment 
by  operation. 

Bunion.^ — ^The  discomfort  of  hallux  valgus  is  caused  in  great 
part  by  the  irritated  biu-sa  and  the  overlying  callus.  These  symp- 
toms may  be  relieved  by  rest  and  by  hot  applications.  Afterward 
the  callus  or  corn  may  be  removed,  and  the  sensitive  bursa  may  be 
protected  by  a  bunion  plaster.  Operative  treatment  should  be 
deferred  until  after   the  acute  s^Tnptoms  have  subsided. 

HAMMER-TOE. 

Hammer-toe  is  a  contraction  of  one  of  the  toes,  usually  of  the 
second,  in  which  the  first  phalanx  is  dorsiflexed,  the  second  plantar 
flexed,  while  the  third  may  be  flexed  or  extended.  The  contracted 
toe  is  overlapped  by  its  fellows;  its  projecting  dorsal  siu-face  is 
subjected  to  the  pressure  of  the  upper  leather  of  the  shoe,  and  the 
terminal  phalanx,  forced  against  the  sole  of  the  shoe  and  com- 
pressed by  the  adjoining  toes,  becomes  flattened  into  a  club  or 
hammer-like  form.  The  nail  is  distorted  and  often  "ingrown;" 
in  most  cases  a  corn  or  callus  forms  upon  the  extremity  of  the  toe, 
and  a  small  bursa  and  corn  over  the  projecting  knuckle  on  the  dorsal 
surface.  A  third  corn  or  callus  is  often  found  beneath  the  head  of 
the  metatarsal  bone  which  has  been  forced  downward  by  the  flexion 
of  the  toe. 

Hammer-toe  is  usually  bilateral;  it  may  be  congenital  and  even 
hereditary,  but  it  is  usually  caused  by  shoes  that  are  too  short 
and  too  narrow.    The  second  toe  is  deformed  most  often,  because 


HAMMER-TOE 


755 


it  is  the  longest  and  because  it  suffers  most  from  the  lateral  com- 
pression as  well.  The  deformity  begins,  as  a  rule,  in  early  childhood, 
when,  the  growth  of  the  foot  being  rapid,  it  is  more  likely  to  suffer 
from  the  effects  of  outgrown  shoes,  and  socks  also. 

Symptoms. — ^The  symptoms  are  practically  those  of  the  corns 
or  blisters  caused  by  the  pressure  of  the  shoe,  but  they  are  often 
sufficiently  troublesome  to  interfere  seriously  not  only  with  the 
comfort,  but  with  the  ability  of  the  patient. 

Treatment. — ^The  resistance  to  the  rectification  of  the  deformity 
is  caused  by  the  accommodative  changes  that  follow  habitual 
malposition.  In  cases  of  long  standing  all  the  tissues  may  be 
involved  in  the  contraction,  of  which  the  most  resistant  are  the 
shortened  capsular  and  lateral  ligaments  of  the  first  interphalangeal 
joint. 


Fig.  581. — Hammer-toe,  hallux  valgus,  and  flat-foot. 


The  congenital  hammer-toe  of  the  infant  may  be  treated  by 
daily  manipulation,  the  toe  being  held  in  proper  position  by  narrow 
strips  of  adhesive  plaster  passed  over  and  under  it  and  about  its 
fellows  or  a  thin  strip  of  lead  may  be  moulded  about  the  toes  for 
the  same  purpose.  In  older  children  a  digitation  in  the  stocking 
will  often  hold  the  toe  in  place  if  the  deformity  is  slight  and  if  a  wide 
shoe  is  worn.  In  adult  cases,  in  addition  to  the  manipulation  and 
shoe,  a  retention  apparatus,  in  the  form  of  a  light  plantar  splint, 
or  stiffened  inner  sole  to  which  the  toe  can  be  attached,  should  be 
worn.  If  the  deformity  is  more  resistant  the  toe  may  be  straightened 
by  force,  aided,  if  necessary,  by  the  subcutaneous  division  of  the 
contracted  ligaments;  but  in  ordinary  cases  the  only  effective 
treatment  is  resection  of  the  joint  for  the  purpose  of  inducing  anchy- 
losis. Sufficient  bone  should  be  removed  to  permit  the  correction  of 
the  deformity,  or,  in  case  of  its  recurrence,  to  prevent  the  projec- 
tion of  the  joint  above  its  fellows.  A  splint  of  celluloid  or  other 
material  should  be  worn  for  a  time.  By  this  operation  permanent 
relief  may  be  assured,  and  it  is  to  be  preferred  to  the  mutilation  of 
amputation. 


756       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

INGROWN    TOE-NAIL. 

Ingrown  toe-nail  is  a  direct  result  of  improper  shoes.  The  most 
important  predisposing  cause  is  weak  foot.  Both  factors  must  be 
considered  in  treatment,  operative  or  otherwise. 


Fig.  582 


Fig.  583 


Fig.  58^ 


The  figures  (Webb)  illustrate  an  effective  treatment  of  the  milder 
t^'jDe  of  this  affection.  A  square  of  adhesive  plaster  is  placed  at 
the  base  of  the  nail.  Twisted  silver  wire,  No.  26,  is  drawn  beneath 
the  nail  and  is  fixed  in  position  by  adhesive  strips.  If  all  pressure 
is  removed  the  normal  relation  of  the  nail  to  the  lateral  tissue  is 
gradually  restored. 

OVERLAPPING    TOES. 

Overlapping  toes  are  A^ery  common  among  adults,  owing  to  the 
pressure  of  the  narrow  shoe;  and  not  infrequently  such  deformity 
is  seen  in  infancy  of  apparently  congenital  origin.  Deflected  or 
deformed  toes  may  be  treated  in  infancy  by  manipulation  and  by 
support  in  the  manner  described. 

In  childhood  persistent  manual  correction  and  proper  shoes  will 
usually  overcome  acquired  deformity.  In  older  subjects  an  inner 
sole  somewhat  like  a  sandal,  to  which  the  toes  may  be  attached  by 
bands  of  tape,  may  be  employed  if  the  deformity  is  considered  of 
sufficient  importance  by  the  patient  to  demand  treatment. 


EXOSTOSES    OF    THE   FOOT. 

Simple  exostoses  of  the  foot,  as  distinct  from  those  that  are 
congenital  or  incidental  to  disease,  are,  in  most  instances,  induced 
by  pressm'e  upon  a  projecting  bone  of  a  sonjewhat  deformed  foot. 
The  common  examples  are  the  hA'pertrophy  of  the  navicular  (often 
seen  in  weak  foot  of  young  children),  the  projection  of  the  cunei- 
form bones  on  the  dorsum  of  the  hollow  or  contracted  foot,  the  thick- 


SUPERNUMERARY  BONES  757 

ening  of  the  internal  condyle  of  the  first  metatarsal  bone  compli- 
cating hallux  valgus.  Exostoses  on  the  posterior  aspect  of  the  os 
calcis  often  accompanying  achillobursitis,  or  those  on  its  under  sur- 
face are  often  the  result  of  infectious  diseases,  particularly  gonorrhea. 
•  As  a  rule  the  treatment  of  the  deformity  of  the  foot  and  the 
removal  of  pressure  will  relieve  the  symptoms  without  other  treat- 
ment. Operative  removal  is  indicated  when  such  treatment  is  not 
effective. 

Subungual  Exostoses. — In  some  instances  the  "exostosis"  is  a 
duplication  of  a  terminal  phalanx,  causing  elevation  of  the  nail  and 
discomfort.     Operative  removal  is  indicated. 

FRACTURE    OF    THE   METATARSAL   BONES. 

Fractm'e  of  a  metatarsal  bone,  most  often  near  the  anterior 
extremity  of  the  second  or  the  fifth,  may  occur  without  apparent 
cause  other  than  walking.  The  pain  and  the  subsequent  swelling 
in  such  cases  may  be  inexplicable  until  the  diagnosis  is  made  clear 
by  an  cc-ray  picture.  The  accident  is  well  known  in  military  practice 
as  an  incident  of  marching.  The  symptoms  may  be  relieved  in 
most  instances  by  plaster  strapping  and  by  a  steel  sole  plate  that 
supports  the  metatarsal  arch. 


Fig.  585.— Congenital  exostosis  of  the  fifth  metatarsal  bone. 

SUPERNUMERARY   BONES. 

Supernumerary  bones  are  of  chief  importance  because  they  may 
be  mistaken  in  .r-ray  pictures  for  small  fragments  broken  from 
the  adjoining  bone,  particularly  as  they  are  often  unilateral.  In 
order  of  importance  they  are : 

1.  The  OS  trigonum,  at  the  base  of  the  posterior  surface  of  the 
astragalus,  behind  the  internal  or  external  tubercle. 

2.  Os  tibiale  externum,  behind  and  below  the  tubercle  of  the 
scaphoid. 


758       DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT 

3.  Os  peroiieale,  apparently  a  sesamoid  bone  in  the  tendon  of 
the  peroneus  longus  at  the  anterior  outer  extremity  of  the  os  calcis. 

4.  Os  VesaHi,  at  the  base  of  the  fifth  metatarsal  bone. 

5.  Secondary  os  calcis,  at  the  supero-anterior  extremity  of  the  os 
calcis. 

6.  Intercuneiform,  between  the  external  and  middle  cuneiform 
bones. 

7.  Intermetatarsmn,  between  the  bases  of  the  first  and  second 
metatarsal  bones. 

The  group  1  to  4  is  fairly  common,  5  to  7  rare. ^ 
In  100  consecutive  .r-ray  pictures  of  healthy  feet,  supernumerary 
bones  were  present  in  30. 

DISPLACEMENT   OF   THE   PERONEI   TENDONS. 

Permanent  displacement  of  these  tendons  forward  of  the  mal- 
leolus is  not  uncommon  as  a  result  of  paralytic  deformity,  par- 
ticularly talipes  calcaneus,  and  in  such  instances  it  gives  rise  to 
no  sjTiiptoms.  Displacement  of  one  or  both  of  the  tendons,  or 
rather  a  laxity  of  their  attachments  that  allows  an  occasional 
displacement  or  slipping  from  the  groove  behind  the  malleolus, 
may  cause  serious  disability,  because  of  the  pain  that  follows  the 
displacement  and  because  of  the  weakness  and  insecurity  of  which 
the  patient  usually  complains. 

The  cause  of  the  laxity  of  the  tissues  that  allows  displacement 
in  feet  otherwise  normal  may  have  been  injury,  but  as  the  affec- 
tion is  often  bilateral,  the  predisposition  may  be  congenital. 

Treatment. — If  the  displacement  is  recent,  as  when  it  follows 
injury,  the  tendons  should  be  replaced,  and  the  foot  should  be 
fixed  in  a  plaster  bandage  until  repair  has  taken  place.  If,  as  in 
certain  instances,  dorsal  flexion  is  limited,  the  restriction  should 
be  overcome  before  the  bandage  is  applied.  If  the  displacement 
is  habitual,  a  brace  may  be  applied  to  restrain  those  motions  at  the 
ankle  that  induce  it.  In  cases  of  the  milder  type  a  tentative 
treatment  by  adhesive-plaster  strapping  so  applied  as  to  prevent 
dorsal  flexion  and  abduction  may  be  efi^ective.  In  chronic  cases 
an  operation  with  the  aim  of  fixing  the  tendons  by  suturing  the 
displaced  sheath  in  its  normal  position  or  by  deepening  the  groove, 
may  be  indicated.  If  on  examination  the  cause  of  the  displacement 
appears  to  be  a  shortening  of  a  tendon  it  may  be  divided  and 
lengthened  in  the  ordinary  manner. 

SHOES. 

The  shoe  as  a  factor  in  the  etiology  of  deformity  and  disability 
has  been  mentioned  several  times  in  the  preceding  pages,  but  it  is  a 
subject  of  such  importance  that  it  deserves  especial  consideration. 

1  Geist:  Am.  Jour,  of  Orth.  Surgery,  1914. 


bhoes 


759 


The  object  of  the  shoe  is  to  cover  and  to  protect  the  foot;  there- 
fore the  one  should  correspond  to  the  shape  of  the  other.  If  the 
feet  are  placed  side  by  side  the  outline  and  the  imprint  of  the  soles 
will  correspond  to  the  accompanying  diagram  (Fig.  586).  The 
.outline  demonstrates  the  actual  size  and  shape  of  the  apposed  feet, 
emphasized  by  enclosing  them  in  straight  lines.  Thus,  each  foot 
appears  to  be  somewhat  triangular,  being  broad  at  the  front  and 
narrow  at  the  heel.  The  imprint  shows  the  area  of  bearing  surface, 
and  owing  to  the  fact  that  but  a  small  portion  of  the  arched  part  of 
the  foot  rests  upon  the  ground  it  appears  to  be  twisted  inward. 
The  sole  of  the  shoe,  if  it  is  to  enclose  and  support  the  bearing 
surface,  must  conform  to  this  inward  turn.  It  must  be  straight 
along  the  inner  border  to  follow  the  normal  line  of  the  great  toe, 
and  a  wide  outward  sweep  will  be  necessary  in  order  to  include  the 
outline  and  thus  avoid  compression  of  the  outer  border  of  the  foot 
(Fig.  587). 


Fig.  586.— Normal  feet. 


Fig.  587. — Proper  soles  for  normal  feet. 


This  demonstration  of  the  true  form  of  the  foot  is  almost  an 
indispensable  preliminary  to  an  intelligent  discussion  of  the  relative 
merits  of  shoes,  and,  indeed,  it  is  somewhat  of  a  revelation  to  those 
who  have  thought  of  the  foot  only  as  it  has  been  subordinated  to 
the  arbitrary  and  conventional  standard  of  the  shoemaker.  The 
shoemaker's  foot,  to  which  lasts  conform,  is  much  narrower  than  the 
actual  foot;  the  great  toe  is  not  a  powerful  movable  member,  pro- 
vided with  active  muscles,  but  is  small  and  turns  outward,  so  that 
the  forefoot  is  somewhat  pyramidal  in  form  and  turns  upward  as 
if  to  avoid  contact  with  the  ground.  This  imaginary  foot,  drawn 
after  the  shape  of  the  ordinary  last,  appears  in  the  diagrams  (Figs. 
588  and  589).  Upon  it  the  sole  of  the  shoe  has  been  indicated,  to 
contrast  it  with  the  shape  of  that  necessary  to  include  the  outline 
of  the  normal  foot.    The  actual  foot  is  thus  compressed  laterally 


760       DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 


Fig.  588. — Shoemaker's  feet,      f  Fig.  589. — Shoeniaker'slsoles. 


Fig.  590. — Skiagram  of  a  foot  modelled  to  fit  the  shoe,  illustrating  the  etiologj'  of 

hallux  valgus. 


SHOES  761 

by  the  shoe  until  the  stretching  of  the  leather,  during  the  "breaking- 
in"  process,  allows  it  to  overhang  the  sole.  The  great  toe  is  forced 
outward,  and,  with  its  fellows,  is  compressed,  distorted,  and  lifted 
off  the  ground  by  the  rocker-shaped  sole  (Fig.  591).  Finally, 
although  in  the  foot  there  is  a  well-marked  metatarsal  arch  (con- 
vexity upward),  the  sole  is  made  with  a  convexity  downward. 
Thus  the  foot,  according  to  the  age  at  which  the  reshaping  process 
is  begun  and  the  constancy  of  the  application,  is  gradually  changed 
in  shape  and  altered  in  function  (Fig.  590). 

This  remodelling,  however,  is  often  accompanied  by  such  dis- 
comfort that  the  individual  rebels  and  wears  a  shoe  with  a  square 
toe,  which,  from  the  conventional  stand-point,  is  supposed  to  show  a 
meritorious  effort  to  follow  nature.  But  the  demonstration  of  the 
actual  foot  makes  it  evident  that  it  is  a  properly  shaped  sole  which 
serves  as  a  support,  not  the  part  which  projects  beyond  the  foot, 
that  is  of  importance.  If  the  shoe  with  the  square  toe  is  wider, 
and  straighter  on  the  inner  side  than  another  with  a  pointed  toe, 
it  is  insofar  an  improvement.  But,  as  a  matter  of  fact,  one  of  the 
worst  types  of  shoe  owes  its  popularity  to  the  square  toe. 


Fig.  591.— The  rocker  sole.  Fig.  592.— The  flat  sole. 

The  object  of  the  heel  is  to  make  walking  easier  by  inclining 
the  body  somewhat  forward.  The  high,  narrow  heel  is  an  insecure 
support,  which  induces  deformity  by  throwing  more  strain  upon 
the  forefoot  and  pushing  it  forward  into  the  narrowest  part  of  the 
shoe.  The  heel  is,  of  course,  unnecessary  in  childhood,  and  should 
not  be  worn,  since  it  limits  the  necessity  for  and  therefore  the  use 
of  the  normal  range  of  motion  of  the  ankle-joint.  The  ordinary 
shoe,  with  its  stiff  shank,  by  restricting  the  functional  use  of  the 
foot,  favors  awkwardness  and  improper  attitudes.  It  compresses 
the  toes,  and  is  directly  responsible  for  corns,  bunions,  ingrown 
toe-nails,  and  deformities,  and  indirectly  causes  or  aggravates  nearly 
every  weakness  to  which  the  foot  is  liable.  This  assertion  does  not 
need  support  of  argument,  since  in  some  degree  it  has  been  proved 
by  the  personal  experience  of  every  shoe  wearer. 

The  shape  of  the  proper  shoe  corresponding  to  the  undistorted 
foot  has  already  been  demonstrated  (Fig.  587).  The  sole  should 
be  thick  enough  for  protection,  but  not  so  rigid  as  to  limit  normal 
motion;  it  should  follow  the  imprint  of  the  foot,  projecting  some- 


762        DISABILITIES  AND  DEFORMITIES  OF   THE  FOOT 

what  beyond  the  outhne  of  the  toes;  it  should  be  flat  from  end  to 
end  and  from  side  to  side  (Fig.  592),  and  the  upper  leather  should 
be  capacious.  In  other  words,  the  front  of  the  shoe  should  be 
designed  to  permit  and  to  encourage  normal  functional  activity, 
the  slight  adduction  of  the  great  toe,  and  the  alternate  expansion 
and  contraction  of  its  fellows,  as  may  be  observed  in  the  barefoot 
child.  The  heel  should  be  broad  and  low"  and  the  shank  should  be 
narrow  so  that  the  upper  leather  may  be  properly  fitted  to  the  arch. 
It  should  not  be  braced  or  stiffened  but  flexible  in  order  to  conform 
to  the  sole  and  to  permit  free  movement.  Most  adiflt  feet  are  more 
or  less  deformed,  and  therefore  better  suited  by  an  improved  than 
by  a  perfect  shoe.  In  selecting  shoes,  the  breadth  of  sole,  the  angle 
of  outward  deviation  of  the  soles  when  the  two  are  placed  side  by 
side,  and  the  capacity  of  the  upper  leather  must  be  the  determining 
points. 

Rubber  heels  should  not  be  worn  by  yomig  and  vigorous  indi- 
viduals. Elasticity  in  gait  is  assured  by  the  action  of  the  calf 
muscle,  not  by  a  yielding  substance  beneath  the  heels. 

The  most  eftective  work  for  reform  can  be  accomplished  by  pro- 
viding proper  shoes  for  children  and  thus  preventing  deformity. 
The  inspection  of  children's  feet  shows  that  atrophy  and  compres- 
sion begin  at  a  very  early  age,  and  if  protection  could  be  assured 
during  the  period  of  rapid  growth,  serious  distortion  might  be 
prevented. 

Socks. — Although  of  far  less  importance  than  the  shoes,  the  socks 
worn  by  children  deserve  special  mention  as  a  factor  in  deformity, 
since  they  are  often  too  short  and  too  narrow  and  are  made  of 
unyielding  material,  so  that  the  proper  action  of  the  toes  is  restrained. 
The  socks,  like  the  shoes,  should  be  rights  and  lefts,  but  as  these 
are  not  in  common  use  one  must  select  those  sufiiciently  large  and 
of  a  vielding  texture. 


CHAPTER    XXII. 
DEFORMITIES  OF  THE  FOOT. 

TALIPES. 

In  the  preceding  chapters  the  disabiUties  of  the  foot,  of  which  the 
symptoms  were  of  greater  importance  than  actual  deformity,  have 
been  described.  One  now  passes  to  the  consideration  of  the  con- 
genital and  acquired  disabilities,  of  which  deformity  is  the  most 
noticeable  feature. 


Fig.  593. — Paralytic  equinus.     Recovery  from  paralysis,  but  deforiBity  persists. 

Distortions  of  the  foot  are,  practically,  fixed  positions  in  normal 
attitudes  or  what  are  exaggerations  of  normal  attitudes;  in  other 
words,  the  ordinary  deformities  can  be  voluntarily  simulated,  and 
the  centres  of  motion,  at  which  the  foot  is  deformed,  are  the  centres 
of  normal  motion.  If  the  foot  has  been  fixed  in  the  abnormal  atti- 
tude during  the  period  of  formation  and  rapid  growth,  or  if  it  has 
been  used  for  any  length  of  time  in  the  abnormal  position,  the 
deformity  becomes  exaggerated  beyond  the.  possibility  of  imitation, 
and  secondary  variations  in  its  shape,  size,  and  nutrition  follow. 


764  DEFORMITIES  OF   THE  FOOT 

The  deformities  of  the  foot  are  grouped  under  the  generic  name 
of  talipes,  derived  from  talus  (ankle)  and  pes  (foot),  signLf^'ing, 
therefore,  a  fonn  of  defonnity  in  which  the  patient  walks  upon  his 
ankles.  Talipes  was  thus  originally  synonymous  with  the  popular 
term  club-foot,  but  at  the  present  time  it  is  used  simply  as  a  prefix 
to  the  descriptive  titles  of  the  different  distortions,  while  club-foot 
is  usually  applied  only  to  the  most  common  of  the  congenital 
deformities,  equinovarus.  in  which  the  distorted  foot  is  club-like 
in  form. 

Varieties. — There  are  four  simple  varieties  of  the  distorted  foot 
or  talipes. 

1.  Talipes  Equinus,  the  extended  or  plantar  flexed  foot.  In  well- 
marked  cases  the  patient  walks  upon  the  heads  of  the  metatarsal 
bones,  an  attitude  that  suggested  the  name  equinus  ( horse-like  j. 

2.  Talipes  Calcaneus,  the  dorsiflexed  foot,  in  which  the  heel  is 
prominent,  and  which  alone  bears  the  weight  in  walking:  hence 
calcaneus,  from  calcaneiun,  the  heel  bone. 

In  these  forms  the  centre  of  motion  is  at  the  ankle-joint.  Under 
the  terms  equinus  and  calcaneus  are  included  not  only  the  cases  of 
marked  deformity,  but  also  those  in  which  the  range  of  dorsal  or 
plantar  flexion  is  sufficiently  limited  to  interfere  with  function,  even 
though  the  change  in  the  contour  of  the  foot  is  slight. 

3.  Talipes  Varus,  the  inverted  foot.  In  this  deformity  the  foot  is 
turned  in  or  adducted,  and  combined  with  the  inward  twist  there  is 
practically  always  a  con-esponding  degree  of  inversion;  that  is,  the 
imier  border  of  the  sole  is  elevated  and  the  outer  border  is  depressed, 
so  that  the  weight  falls  to  the  outer  side  of  the  centre  of  the  foot. 

4.  Talipes  Valgus,  the  everted  foot.  This  deformity  is  the  reverse 
of  varus.  The  foot  is  abducted  and  the  sole  is  everted,  so  that  in 
'use  the  weight  falls  on  the  inner  border. 

In  these  forms  of  lateral  deformity  the  centres  of  motion  are  at 
the  mediotarsal  and  subastragaloid  joints. 

Compoimd  Deformities. — Simple  deformities,  in  which  the  foot 
is  persistently  extended  or  flexed,  or  turned  in  or  out,  are  compara- 
tively micommon.  ^Nlore  often  they  are  combined  in  varying 
degree;  thus  the  overextended  or  the  overflexed  foot  is  usually 
twisted  inward  or  outward,  making  four  varieties  of  compoimd 
deformity : 

1.  Talipes  Equinovarus,  the  extended  and  inverted  foot. 

2.  Talipes  Equinovalgus,  the  extended  and  everted  foot. 

3.  Talipes  Calcaneovanis,  the  flexed  and  inverted  foot. 

4.  Talipes  Calcaneovalgus,  the  flexed  and  everted  foot. 

In  the  various  forms  of  talipes  the  arch  may  be  increased  or 
diminished  in  depth.  It  i^.  for  example,  usually  increased  in  cal- 
caneus and  equinus,  and  it  is  usually  diminished  in  valgus;  but 
this  secondary  or  subordinate  deformity  is  not  recognized  in  the 
ordinary  classification.     If  the  arch  of  the  foot  is  simply  exaggerated. 


TALIPES 


765 


the  condition  is  sometimes  called  pes  cavus;  if  it  is  lessened  or  lost, 
it  is  called  pes  planus.  These  slight  degrees  of  distortion,  in  which 
the  functional  disability  is  usually  more  important  than  the  deform- 
ity, are  rarely  classed  as  forms  of  talipes.  Simple  cavus,  the  hollow 
or  contracted  foot,  and  pes  planus,  one  of  the  forms  of  the  common 
weak  or  flat-foot,  have  been  described  elsewhere.  (Chapters  XX 
and  XXI.) 


Fig.  594. — Congenital  calcaneus.    In  this  form  (simple  calcaneus)  the  arch  is  obliter- 
ated.    In  the  acquired  form  (calcaneocavus)  it  is  increased. 

Etiology. — From  the  remedial  stand-point,  the  cause  of  the 
deformity  is  of  far  greater  importance  than  its  form.  Thus,  one 
divides  the  distortions  of  the  foot  into  two  groups: 

1.  The  Congenital  Form,  in  which  the  foot,  in  process  of  forma 
tion,  has  become  deformed  before  birth. 

2.  The  Acquired  Form,  in  which  the  foot,  perfect  at  birth,  has  at  a 
later  time  become  distorted. 

The  congenital  deformity  may  be  considered  simply  as  a  twisted 
foot,  of  which  the  component  parts,  although  distorted  to  a  greater 
or  less  deg-ree,  are  capable  of  regaining  perfect  form  and  function. 
This  is  practically  true  of  the  great  majority  of  cases,  although  there 
are  cases  complicated  by  defective  formation  of  the  foot  or  leg,  or 
by  paralysis;  as,  for  example,  in  certain  forms  of  spina  bifida  or 
other  congenital  defect  or  disease  of  the  nervous  apparatus. 


766 


DEFORMITIES  OF   THE  FOOT 


The  acquired  deformity  is  nearly  always  a  consequence  of  disease 
of  the  spinal  cord  (anterior  poliomyelitis).  The  motive  power  is 
unbalanced  by  the  paralysis  of  certain  muscles  and  distortion  is 
induced  by  the  contraction  of  the  unopposed  muscles  and  by  the 
influence  of  gravity.  This  distortion  is  confirmed  and  increased 
by  the  accommodative  changes  in  structure  that  accompany  func- 
tional use  and  growth  in  the  abnormal  attitude. 

Far  less  often  acquired  talipes  is  the  result  of  paralysis  of  cerebral 
origin,  of  other  forms  of  disease  of  the  spinal  cord,  or  of  local  paraly- 
sis following  neuritis  or  injury  to  a  nerve  trunk.  It  may  be  induced 
by  scar  contraction,  as  after  a  severe  burn,  or  by  direct  injury,  or 
by  disease  that  may  interfere  with  subsequent  gro^i;h.  Such  are, 
however,  extremely  uncommon  causes.  Thus  it  is  evident  that 
while  congenital  talipes  is  a  simple  distortion  capable  of  perfect 
cure,  acquired  talipes,  though  easily  corrected,  cannot  be  cm"ed 
unless  recovery  from  the  original  disease,  of  which  it  is  a  Result, 
has  taken  place. 


Fig.  59.5. — Congenital  valgus. 

Etiology  of  Congenital  Talipes. — As  of  other  congenital  deformities, 
the  etiology  of  talipes  is  conjectiu-al.  Occasionally  the  influence 
of  inheritance  is  apparent,  and,  again,  two  or  more  children  with 
club-foot  may  be  born  of  the  same  mother;  but,  as  a  rule,  nothing 
bearing  upon  the  deformity  appears  in  the  family  or  personal  his- 
tory. The  most  reasonable  explanation  as  applied  to  the  majority 
of  cases  is  the  mechanical.  This  is,  in  brief,  the  theory  that  the 
foot  has  from  some  cause  remained  for  a  longer  or  shorter  time  in  a 
constrained  or  fixed  position,  and  has  thus  grown  into  deformity. 

It  has  been  claimed  by  Eschricht^  and  also  by  Berg-  that  about 
the  third  month  of  intra-uterine  life  the  thighs  of  the  embryo  are 
abducted,  flexed,  and  rotated  outward,  the  legs  are  crossed,  and  the 


1  Deutsch.  Klinik,  1S51,  No.  44. 

2  Berg:  .\rch.  Med.,  New  York,  December  1,  1882. 


TALIPES 


767 


feet  are  plantar  flexed  and  adducted,  so  that  the  inner  surfaces  of 
the  thighs,  the  tibial  borders  of  the  legs,  and  the  plantar  surfaces  of 
the  feet  are  held  in  close  apposition  to  the  abdomen  and  to  the  pelvis 
of  the  fetus.  Later  there  is  an  inward  rotation  of  the  limbs,  the  feet 
turning  gradually  outward  until  the  soles  are  brought  into  con- 
tact with  the  uterine  wall,  the  feet  then  being  in  the  attitude  of 
abduction  and  dorsal  flexion.  According  to  this  theory,  there  is  a 
regular   succession  of   attitudes   during   intra-uterine   life.     If  the 


Fig.  59(3. — Congenital  club-hands  and  feet,  combined  with  anchylosis  of  nearly  all 
the  joints.     (Compare  with  Fig.  597.) 

inward  rotation  of  the  lower  extremity  is  prevented  or  if  it  is  incom- 
plete, the  foot,  remaining  in  the  original  position,  becomes  deformed. 
Thus  equinovarus,  being  the  normal  attitude  of  the  early  and  middle 
period  of  intra-uterine  life  is  the  most  common,  and  the  most  intract- 
able of  the  congenital  deformities.  If  the  constraint  or  pressure  is 
not  exerted  until  after  rotation  has  taken  place,  when  the  foot  has 
attained  or  nearly  attained  its  normal  size  and  shape,  it  will  then 
induce  the  rarer  and  comparatively  slight  grades  of  deformity,  such 
as  calcaneus  or  valgus. 


768 


DEFORMITIES  OF   THE  FOOT 


This  theory,  which  seems  interesting  and  reasonable,  appears  to 
rest  on  a  very  insecure  basis.  Bessel  Hagen^  states  that  in  embryos 
of  30  mm.  in  length  the  foot  is  in  extreme  plantar  flexion;  in  those 
of  90  to  100  mm.  the  foot  is  at  a  right  angle  to  the  leg;  and  from  this 
size  to  that  at  full  term  the  foot  may  be  found  in  any  position- 
abducted,  adducted,  or  dorsiflexed.  He  states,  also,  that  inversion 
is  not  the  usual  attitude  at  an  early  period,  but  is  more  common 
near  the  termination  of  intra-uterine  life,  and  when  it  is  present  it  is 
more  often  combined  with  dorsiflexion.  In  other  words,  there  is 
no  time  when  the  foot  regularlv  and  normallv  assumes  the  attitudes 


Fig.  597. — The  etiologj-  of  congenital  club-hands,  club-foot,  and  anchjdosis  of  the 
joints.    The  attitude  at  birth.    Photograph  at  age  of  three  months.    (See  Fig,  596.) 


of  club-foot,  from  which  it  is  changed  by  the  rotation  of  the  limbs. 
Scudder,-  after  similar  investigations,  arrived  at  practically  the 
same  conclusions.  He  states  that  there  is  no  necessary  relation 
between  the  age,  the  rotation  of  the  limbs,  and  the  position  of  the 
feet. 

Whether  or  not  there  may  be  a  more  or  less  regular  change  in 
posture  during  fetal  life  it  is  evident  that  constraint  favors  deform- 
ity.    If  the  constraint  is  slight,  and  if  its  influence  is  exerted  at  a 

1  Die  Pathologie  und  Therapie  des  Klumpfusses  Heidelberg,  1899. 
-  Boston  Med.  and  Surg.  Jour.,  October  27,  1887. 


TALIPES  769 

late  period,  the  deformity  will  be  slight;  if  it  persists  from  an  early 
period,  the  deformity  will  be  extreme  and  resistant. 

One  of  the  causes  of  constraint,  and  thus  of  ultimate  deformity, 
appears  to  be  the  interlocking  of  the  feet.  Many  museum  speci- 
mens show  this,  and  in  some  of  the  cases  of  talipes  seeji  during  the 
first  weeks  of  life  the  feet  may  be  replaced  in  the  attitude  in  which 
they  had  been  fixed  before  birth  (Fig.  595) .  Intra-uterine  pressure, 
although  not  usually  the  direct  cause  of  club-foot,  undoubtedly  has 
an  influence  in  aggravating  the  deformity.  The  effect  of  pressure 
is  not  infrequently  shown  in  atrophic  areas  of  skin,  and  bursse  even 
are  sometimes  found  over  prominent  bones. 


Fig.  598. — Intra-uterine  "amputations."     The  patient  is  a  tailor. 

Entanglement  in  the  umbilical  cord,  the  direct  pressure  of  intra- 
uterine or  extra-uterine  tumors  and  the  like  may  be  mentioned  also 
as  possible  causes. 

Evidence  of  restraint  and  of  abnormal  attitudes  of  the  limbs 
is  seen  not  infrequently  in  connection  with  club-foot;  for  example, 
in  hyperextension  or  fixed  flexion  of  the  knees,  and  in  extreme 
deformity,  the  foot  is  often  smaller  than  normal  and  otherwise 
asymmetrical. 

The  distorted  foot  may  be  imperfect  in  structure;  toes  may  be 

absent,  "spontaneous  amputation"  (Fig.  598)  or  constricting  bands 

about  the  leg  or  foot  may  be  present.     Such  abnormalities  are 

usually  ascribed  to  amniotic  adhesions.     Talipes  may  be  combined 

49 


770 


DEFORMITIES  OF   THE  FOOT 


with  evidences  of  impaired  or  arrested  development;  with  hare-hp, 
extrophy  of  the  bladder,  spina  bifida,  and  absence  of  patellae ;  or 
with  other  deformities,  such  as  club-hand  and  wry-neck,  fixed 
flexion  at  the  knees,  and  the  like;  or  there  may  be  evidence  of  intra- 
uterine disease,  as  in  anchylosis  of  joints  (Fig.  596)  or  so-called  fetal 
rickets.  Finally,  deformities  of  the  foot  may  be  accompanied  by 
other  deformities  and  malformations,  showing  evidently  an  abnor- 
mality in  the  original  make-up  of  the  germ.  This  latter  group, 
which  includes  the  complications  of  club-foot  and  imperfection  of 
structure,  is  comparatively  small,  for,  as  has  been  already  stated, 
in  the  great  majority  of  cases  congenital  club-foot  is  a  deformity 
capable  of  perfect  cure. 

Statistics. — The  most  accurate  statistics  are  those  compiled 
from  the  records  of  the  Hospital  for  Ruptured  and  Crippled,^  of 
4718  individual  cases  of  talipes.  Of  these  2103  were  congenital  and 
2615  were  acquired.  The  relative  frequency  of  the  congenital  and 
acquired  forms  of  talipes  has  given  rise  to  much  discussion  in  the 
past,  and  statistics  on  this  point  are  at  considerable  variance  with 
one  another.  This  may  be  explained  by  the  fact  that  acquired 
talipes  is,  as  a  rule,  a  preventable  deformity.  At  the  present  time 
the  extreme  degrees  of  acquired  talipes  are  comparatively  rare, 
and  the  deformity  is  usually  of  a  much  slighter  grade  than  the  cor- 
responding form  of  congenital  distortion. 

Males..  Females.                Total. 

Sex  of  congenital  talipes 1355  748                  2103 

Percentage 64.4  35.6 

Sex  of  acquired  talipes 1416  1199                 2615 

Percentage 54.1  45.9 

Congenital  talipes  is  much  more  common  among  males  than 
among  females.  All  statistics  are  in  accord  upon  this  point. 
Acquired  talipes  is  more  equally  divided  between  the  sexes. 


Foot  affected  in  congenital  talipes 

Percentage    

Unilateral  1195   =57.5  per  cent. 


Foot  affected  in  acquired  talipes  . 
Percentage    

Unilateral  2228   =  85. 1  per  cent. 


Right. 

Left.               Both. 

Total. 

643 

552                908 

2103 

30.4 

26.1              43.5 

Bilaten 

ij  918  =  43.5  per  cent. 

Right. 

Left.                Both. 

Total. 

1126 

1102                387 

2615 

43  42 . 1  14 . 9 

Bilateral  387   =14.9  per  cent. 


In  congenital  talipes  the  deformity  is  nearly  as  often  of  both  as 
of  one  foot,  while  in  the  acquired  form  unilateral  deformity  is  far 
more  common.  In  each  variety  the  right  foot  appears  to  be  more 
often  affected  than  the  left. 


1  W.R.  Townsend:  A  Statistical  Paper  on  Club-foot.  Tr.  Med.  Soc.  of  the  State 
of  New  York,  1890.  These  statistics  have  been  supplemented  for  me  by  Drs.  Waller 
and  Weingarten. 


TALIPES 


111 


The  Relative  Fbequenct  of  the  Diffekent  Fobms  of  Congenital  Talipes 

Cases.  Percentage. 

Equinovarus 1629  77.4 

Valgus 144  6.8 

Varus 89  4.2 

Calcaneovalgus 87  4.1 

Equinus ■ 49  2.3 

Calcaneus 47  2.2 

Equinovalgus 35  1.6 

Calcaneovarus 10 

Cavus*     5 

Valgoca\ais 1 

EquinocaATis 1 

Different  deformity  in  each  foot 54 


Relative  Frequency  of  the  Different  Forms  of  Acquired  Talipes  Together 

WITH  THE  Etiology. 


Spinal. 


Anterior 

polio- 
myelitis. 


Cerebral. 


Hemi- 


Para- 
plegia. 


Other 
forms  of 


Trau- 
matic. 


Total. 


Per  cent. 


Equinovarus    . 

610 

Equinus 

469 

Calcaneus 

313 

Valgus 

205 

Equinovalgus 

.    163 

Calcaneovalgus 

123 

Varus    . 

68 

Calcaneovarus 

13 

Equinocaviis   . 

38 

Calcaneovarus 

15 

Cavus  . 

48 

Varocavus 

2 

59 

102 
7 
6 
1 
1 
8 
0 
0 
0 

1 
1 


41 

18 

50 

14 

3 

9 

10 

5 

1 

3 

1 

0 

0 

0 

1 

1 

0 

1 

0 

56 

43 

20 

37 

7 

15 

10 

0 

2 

1 

4 

0 


784 

678 

352 

259 

177 

141 

90 

15 

40 

17 

54 

4 


30.0 
25.9 
13.4 
9.9 
6.7 
5.4 
3.1 
0.5 
1.5 
0.6 
0.2 


2067 


186 


116 


Deformity    differ- 
ent on  each  side 


387     I      —  — 


2611 


Anterior  poliomyelitis 2067   =  79 . 9  per  cent. 

Cerebral 302   =  11.5 

Traumatic 195   =7  " 


Comparative   Frequency  of  the   Different  Forms  of  Talipes,   Congenital 

and  Acquired. 

Congenital  Acquired. 

Equinovarus 77.4  per  cent.  32.5  per  cent. 

Valgus 6.8  "  9.7 

Varus 4.2  "  2.7 

Calcaneovalgus 4.1  "  4.4 

Equinus 2.3  "  26.1 

Calcaneus 1.6  "  12.6 


It  will  be  noted  that  in  three-fourths  of  the  congenital  cases  the 
deformity  is  equinovarus,  and  that  equinus  and  calcaneus,  rare  as 
congenital  deformities,  comprise  more  than  one-third  of  the  acquired 
forms. 


772  DEFORMITIES  OF   THE  FOOT 

Occasionally  the  deformity  is  different  in  each  foot,  far  more 
often  in  the  acquired  than  in  the  congenital  form  (147  of  the  former, 
or  38  per  cent.,  of  the  387  acquired  bilateral  deformities  as  compared 
with  54,  or  less  than  6  per  cent.,  of  the  bilateral  congenital).  In  7 
of  18  of  the  congenital  cases  the  deformity  was  equinovarus  on  one 
side,  calcaneus  on  the  other;  in  3  equinovarus  and  calcaneo valgus, 
and  in  3  simple  varus  and  valgus.  In  congenital  cases  the  most 
common  combination  is  equinovarus  on  one  side  and  calcaneus  on 
the  other.     Xext  equinovarus  and  calcaneovalgus. 

In  31,  or  4  per  cent.,  of  735  cases  of  congenital  talipes  tabulated 
by  Waller  the  distortion  was  combined  with  other  congenital  defects 
or  deformities,  viz.,  in  12  cases  with  double  club-hands;  in  6  cases 
■^ith  defective  development  of  the  hands,  webbed  fingers,  and  the 
like;  in  7  cases  with  spina  bifida;  in  3  cases  with  absence  of  one  or 
more  bones  of  the  leg;  in  1  case  with  torticollis,  in  1  case  ^dth  hare-lip; 
in  1  case  with  dislocation  of  the  knee  and  anchylosis  of  an  elbow; 
in  2  cases  with  general  rigidity  and  deformity  of  the  joints. 

The  Anatomy  of  Congenital  Club-foot. — Talipes  Equinovarus. — 
Congenital  talipes  is,  in  the  great  majority  of  cases,  the  form  in 
which  the  foot  is  twisted  inward  and  downward,  so  that  in  extreme 
cases  it  resembles  the  club-like  extremity  that  has  received  the  popu- 
lar name  of  club-foot.  The  ordinary  congenital  club-foot  in  early 
infancy  is  simply  a  foot  fixed  in  an  exaggerated  attitude  of  plantar 
flexion,  adduction,  and  inversion.  The  dorsum  of  the  foot  looks 
forward  and  slightly  outward  and  upward,  the  plantar  surface  is 
abnormally  concave,  and  looks  backward,  inward,  and  downward. 
The  foot  often  seems  somewhat  smaller  than  normal,  and  the  heel 
appears  to  be  ill-formed.  Upon  the  outer  dorsal  surface  the  body 
of  the  displaced  astragalus  projects;  the  external  malleolus  is  promi- 
nent, while  the  internal  malleolus  lies  deep  beneath  the  redundant 
tissues  of  the  internal  aspect  of  the  foot. 

In  many  instances  the  tmiiing  inward  of  the  foot  is  so  extreme 
that  it  conceals  the  equinus  element  of  the  deformity  (Fig.  599). 
Thus  equinovarus  is  often  classified  as  varus,  especially  by  English 
authors. 

The  internal  structure  of  the  foot  corresponds  to  the  external 
contour;  thus  the  relation  of  the  bones  to  one  another,  and  even 
the  shape  of  the  individual  bones,  are  more  or  less  altered  as  the 
deformity  is  more  or  less  of  an  exaggeration  of  the  attitudes  that 
the  normal  foot  is  capable  of  assuming.  These  changes  are  most 
marked  in  the  astragalus  and  os  calcis.  The  astragalus  is  thicker 
at  its  external  than  at  its  internal  border,  or  somewhat  wedge- 
shaped  from  without  inward;  it  is  plantar  flexed,  so  that  a  large 
part  of  its  body  protrudes  from  between  the  malleoli.  Its  neck  is 
often  somewhat  longer  than  normal,  and  is  depressed  and  deflected 
inward  (Fig.  600,  B) .  The  os  calcis  is  also  in  an  attitude  of  plantar 
flexion;  the  internal  tuberosity  is  drawn  upward  to  the  vicinity  of 


TALIPES 


773 


the  internal  malleolus,  its  anterior  extremity  looks  downward  and 
inward,  and  it  is  often  bent  inward,  corresponding  to  the  deformity 


Fig.  599. — Typical  congenital  equinovarus  (club-foot) . 

of  the  neck  of  the  astragalus.  Its  external  surface  looks  downward 
and  forward,  and  it  lies  directly  beneath  the  astragalus  instead  of 
to  its  outer  side,  as  in  the  normal  relation. 


Fig.  600. — The  deformities  of  the  astragalus  in  club-foot:  A,  astragalus  of  a  normal 
infant;  1,  from  above;  2,  from  within;  3,  from  without.  B,  the  astragalus  in  club- 
foot in  the  same  position.     (Adams.) 

The  navicular  is  drawn  inward  and  upward,  and  articulates  with 
the  inner  part  of  the  deflected  head  of  the  astragalus;  it  lies  in  close 


774 


DEFORMITIES  OF   THE  FOOT 


proximity  to  and  is  often  in  contact  with  the  internal  malleolus;  the 
cuboid  is  displaced  upward  and  inward,  and  lies  to  the  inner  side  of 
the  anterior  extremity  of  the  os  calcis.  The  remaining  bones  are 
changed  in  position,  but  not  materially  in  shape.  In  many  instances 
the  tibia  is  rotated  inward  upon  the  femur,  and  this  inward  rotation 
of  the  leg  may  persist  after  the  deformit\-  of  the  foot  has  been  cor- 
rected.    Less  often  the  tibia  is  slightly  twisted  inward  on  its  long 

axis.  In  other  cases  there  is 
'*^--  "^  often  a  moderate  degree  of 
knock-knee  and  laxity  of  the 
ligaments  at  the  knee.  As  a 
rul.e,  however,  these  are  sec- 
ondary or  compensatory  effects 
of  club-foot  that  do  not  appear 
until  the  child  begins  to  walk. 
The  ligaments  and  muscles 
correspond  to  the  changed 
relations  of  the  bones.  The 
muscles  are  normal  as  to 
their  structure  and  theu' 
origin  and  insertion  but  those 
attached  to  the  imier  side, 
the  extensor  and  adductor 
group,  are  shortened  and  are 
relatively  stronger  than  the 
opposing  muscles  which  are 
lengthened  and  atrophied 
from  disuse. 

To  sum  up:  all  the  com- 
ponent parts  of  the  foot  par- 
ticipate in  the  deformity.  The 
most  resistant  structiu-es  of 
the  deformed  foot  are  the 
plantar  fascia  and  the  liga- 
ments that  bind  the  navicular, 
the  OS  calcis,  and  the  internal 
malleolus  to  one  another. 
The  muscles  that  are  most 
active    in   retaining  and 


Fig.  601. — Talipes  equinovarus  in  adoles- 
cence, apparently  of  the  acquired  form,  show- 
ing the  displacement  of  the  astragalus  and 
its  relation  to  the  scaphoid,  also  the  atrophy 
and  distortion  of  the  bones  of  the  leg. 


m  retamnig  and  m- 
creasing  the  deformity  are  the  tibialis  anticus,  the  tibialis  posticus, 
and  the  combined  gastrocnemius  and  soleus. 

The  changes  that  have  been  outlined,  which  are  comparati^-ely 
slight  and  which  may  be  easily  rectified  soon  after  birth,  become 
more  marked  as  the  part  develops;  and  when  the  child  begins  to 
walk  the  weight  of  the  body,  combined  with  growth  and  functional 
use  in  the  abnormal  position,  increases  and  fixes  the  deformity. 

In  the  adolescent  or  adult  type  of  club-foot  that  has  never  been 


TALIPES 


775 


treated,  the  deformity  is  so  extreme  that  the  patient  actually 
appears  to  walk  on  the  outside  of  his  ankles,  as  the  term  talipes 
implies.  The  feet  turn  directly  inward,  or  even  inward,  upward, 
and  backward,  and  the  peculiar  walk,  by  which  interference  of 
inverted  feet  is  avoided,  has  given  another  name  (reel  foot)  to  the 
deform  itv. 


Fig.  602. — The  tendons  on  the  front 
of  the  foot. 

Figs.  602  and  603.- 


FiG.   603. — Showing  the  tendons  in  the 
sole  of  the  foot  and  the  extreme  displace- 
ment of  the  OS  calcis. 
-Talipes  eqmnovarus. 


In  such  cases  knock-knee  is  usually  well  marked.  This,  although 
it  may  be  present  at  birth  is,  as  has  been  stated,  usually  a  secondary 
distortion  caused  in  great  part  by  the  accommodation  to  the  deform- 
ity; that  is,'  by  the  diminution  of  the  base  of  support  and  by  the 
interference  of  the  feet  (Fig.  604) . 

The  legs  are  shrunken  from  disuse.  Over  the  outer  border  of  the 
foot,  in  the  neighborhood  of  the  calcaneocuboid  articulation,  there 
is  a  large  callus  with  an  underlying  bursa.  The  foot  itself  is  atro- 
phied and  is  smaller  than  the  normal.  The  changes  in  the  bones  are 
much  more  marked;  only  a  small  part  of  the  articulating  surface  of 


776  DEFORMITIES  OF   THE  FOOT 

the  astragalus  lies  between  the  malleoli,  and  this  posterior  extremity 
is  flattened  out  to  the  shape  of  a  wedge.  Thus,  the  leg  bones  appear 
to  be  displaced  backward,  a  change  most  apparent  in  the  position 
of  the  external  malleolus.  The  bones  of  the  foot  are  more  or  less 
atrophied,  and  the  normal  area  of  cartilage  has,  to  a  great  extent, 
disappeared  from  the  articular  surfaces  of  the  disused  joints.. 

In  these  neglected  cases  the  foot  is  practically  a  simple  rigid  sup- 
port, to  which  the  patient  has  been  so  long  accustomed  that  he  may 
walk  with  comparative  ease  and  with  no  discomfort  other  than  that 
caused  by  the  callosities  and  bursse  at  the  pressure  points. 

Symptoms. — The  symptoms  of  congenital  club-foot  have  been, 
to  all  intents,  included  in  the  description  of  the  deformity.  The 
functional  disability  is,  of  coiu*se,  considerable,  although  some 
patients  are  surprisingly  active  and  are  able  to  M^alk  long  distances. 
As  the  discomfort  from  club-foot  is  due  almost  entirely  to  the  corns 
or  inflamed  bursse  over  the  bony  prominences,  its  degree  depends, 
of  course,  upon  the  use  to  which  the  foot  is  subjected. 

Treatment. — In  considering  the  treatment  of  congenital  club-foot 
it  is  customary  to  divide  it  into  several  classes  corresponding  to  the 
degree  of  resistant  deformity. 

The  first  class  would  include  the  very  slight  or  non-resistant  cases 
in  which  the  deformity  may  be  almost  entirely  corrected  by  slight 
manual  force. 

The  second  class  comprises  those  cases  in  which  a  certain  amount 
of  varus  and  well-marked  equinus  persist,  which  it  is  impossible 
to  overcome  by  manipulation. 

The  first  and  second  classes  include  the  forms  of  infantile  club- 
foot. 

The  third  class  comprises  the  cases  of  more  extreme  deformity 
and  those  in  which  the  resistance  to  the  correction  is  great,  as  in 
many  of  the  cases  in  early  childhood  or  those  of  later  years  that 
have  been  inefficiently  treated. 

A  fourth  class  would  include  the  untreated  cases  in  the  adolescent 
or  adult. 

Congenital  club-foot  (talipes  equinovarus)  treated  at  the  proper 
time — that  is  to  say,  in  early  infancy  and  in  a  proper  manner  in  a 
great  majority  of  cases  may  be  perfectly  cured  both  as  to  form  and 
function. 

The  club-foot  in  childhood,  in  which  treatment  has  been  delayed 
or  in  which  it  has  been  ineftective,  may  be  practically  cured  but  a 
certain  limitation  of  motion  and  more  or  less  atrophy  of  the  foot  and 
leg  persists  as  a  consequence  of  the  disuse  of  normal  function. 

Club-foot  in  the  adult  may  be  made  straight,  but  restoration  of 
perfect  function,  is  of  com"se,  impossible. 

Although  congenital  club-foot  is  an  eminently  curable  deformity, 
yet  perfect  and  permanent  cure  requires  minute  attention  to  details 
during  active  treatment,  supplemented  by  careful  super\'ision  long 


TALIPES  777 

after  the  cure  is  supposed  to  be  complete.  No  other  deformity 
presents  such  a  record  of  faihires  and  incomplete  cures,  of  relapses 
after  apparent  cure,  of  tedious  and  ineffective  treatment  by  braces, 
and  of  unnecessary  and  mutilating  operations.  Some  of  the  failures 
may  be  explained  by  neglect  or  by  want  of  opportunity.  A  few 
are  due  to  the  unusual  obstacles  in  the  deformity  itself,  but  by  far 
the  greater  number  must  be  accounted  for  by  failure  of  the  physician 
to  apprehend  the  true  nature  of  the  deformity  or  by  his  inexperience 
in  the  practical  details  of  treatment. 

Principles  of  Treatment  of  Infantile  Club-foot. — ^The  infantile  club- 
foot is,  as  has  been  stated,  simply  a  twisted  foot.  It  is  true  that 
there  are  slight  changes  in  the  bones;  but  the  bones  of  an  infant's 
foot  are  represented  by  yielding  cartilage,  which  will  rapidly  reform 
under  changed  conditions.  The  shortened  tissues  may  be  easily 
stretched  and  when  the  proper  relation  of  the  bones  to  one  another 
has  been  restored  the  joints  will  undergo  an  accommodative  trans- 
formation which  will  permit  normal  movement. 

The  treatment  of  club-foot  may  be  divided  into  three  stages: 

1.  The  rectification  of  the  external  deformity. 

2.  The  support  of  the  foot  in  proper  position  during  the  process 
of  transformation  of  its  internal  structure  and  until  the  normal 
muscular  balance  has  been  regained. 

3.  The  period  of  supervision.  This  would  include  the  treatment 
of  possible  complicating  deformities  at  the  knee,  the  laxity  of  liga- 
ments and  the  like,  as  well  as  the  oversight  of  the  functional  use  of 
the  foot  and  the  limb  during  the  early  years  of  life. 

The  normal  infant  moves  the  foot  in  various  directions,  in  a  more 
or  less  regular  alternation  of  postures,  but  the  motion  of  the  club- 
foot is  in  one  direction  only,  that  toward  which  the  foot  is  turned. 
The  muscles  on  the  back  and  inner  side  of  the  leg,  which  are  alone 
active,  become  relatively  irritable  and  hypertrophied  as  compared 
with  those  on  the  front  and  outer  side  that  are  disused.  Thus  move- 
ment of  the  deformed  foot  is  in  reality  harmful,  because  it  increases 
deformity  and  still  further  disturbs  the  muscular  balance.  For  this 
reason  the  temporary  restraint  of  motion,  necessary  during  the  recti- 
fication of  the  deformity,  may  be  considered  rather  of  advantage 
than  otherwise.  When  movement  is  again  permitted  it  must  be  in 
the  directions  opposed  to  the  deformity. 

The  First  Stage  of  Treatment. — Rectification  of  Deformity. — "Recti- 
fication of  deformity"  must  not  be  mistaken  for  restoration  of  sym- 
metry, a  misapprehension  to  which  the  majority  of  failures  in  treat- 
ment may  be  ascribed.  It  means  that  when  deformity  is  really 
rectified  all  contracted  and  resistant  parts  must  have  been  so  elon- 
gated that  every  passive  motion  and  attitude  possible  for  the  normal 
foot  is  equally  possible  and  as  easily  attained  in  that  which  was 
deformed.  This  is  functional  rectification  as  contrasted  with  the 
simple  correction  of  deformity. 


778  DEFORMITIES  OF   THE  FOOT 

The  most  iinijortant  part  oi  the  deformity  is  varus.  The  foot 
that  is  rolled  over  and  twisted  inward  to  the  attitude  of  extreme 
in^'ersion  (Fig.  599)  must  be  imtwisted  and  placed  in  an  attitude  of 
extreme  abduction  or  ^'algus,  the  so-called  overcorrection  (Fig. 
595).  Lntil  this  is  accomplished  no  attention  whatever  need  be 
paid  to  the  residual  equinus.  There  are  two  reasons  for  this: 
First,  that  the  attention  of  the  surgeon  may  be  concentrated  on  one 
and  the  most  important  part  of  the  deformity;  second,  because  by 
this  prelmiinary  tmtwisting  the  os  calcis  is  brought  into  the  upright 
position,  into  its  proper  relation  to  the  astragalus,  to  the  bones  of  the 
leg,  and  to  the  tendo-Achillis,  so  that  the  true  degrees  of  equinus 
may  be  appreciated. 

Preliminary  Manipulation. — As  a  rule  the  second  or  third  week  of 
life  is  as  early  as  mechanical  treatment  can  be  undertaken.  Until 
then  preliminary  manipulation  by  the  nurse,  more  particularly 
manual  straightening  of  the  deformity  by  gently  drawing  the  foot 
toward  abduction  and  retaining  it  in  the  improved  position  for  a 
few  minutes,  as  often  as  is  possible,  may  be  of  service  in  overcoming 
its  resistance.  As  a  treatment  by  itself,  however,  simple  manual 
correction  is  tedious  and  ineffective,  although  partial  cm"es  have 
been  attained  by  perseverence  in  this  means  alone. 

Mechanical  Treatment. — This  is  the  treatment  of  choice  and  routine 
for  infantile  club-foot,  and  two  methods  may  be  described : 

1.  By  the  plaster  bandage. 

2.  By  some  form  of  simple  splint. 

The  principle  of  the  two  is  essentially  the  same.  The  foot  is 
drawn  toward  an  improved  position  and  retained  there  by  the 
plaster  bandage,  or  it  may  be  fixed  to  some  form  of  metal  splint 
or  brace  whose  shape  is  gradually  changed  from  week  to  week,  as  the 
resistance  lessens. 

Gradual  Rectification  of  Deformity  by  Means  of  the  Plaster  Bandage. 
— ^In  this  treatment  care  should  be  taken  to  a^'oid  undue  pressure, 
irritation  of  the  skin,  or  insecmity  of  the  bandage.  One  should 
place  shreds  of  cotton  between  the  toes;  and  the  outer  aspect  of 
the  ankle,  where  the  skin  is  thro\\m  into  folds  when  the  foot  is 
straightened,  should  be  powdered  or  smeared  with  vaseline.  A  thin 
layer  of  cotton  is  wound  about  the  leg,  just  below  the  knee,  in  order 
to  protect  the  skin  from  the  hard  margin  of  the  plaster  bandage,  and 
a  similar  strip  is  carried  about  the  toes.  The  foot  is  then  drawn 
gently  toward  the  abducted  position  as  far  as  may  be  without  caus- 
ing discomfort.  ^Yhile  it  is  held  in  this  attitude  a  narrow  bandage, 
preferably  flannel  or  cotton  flannel,  is  smoothly  applied  to  the  leg 
and  foot. 

A  very  light  plaster  bandage  is  then  applied  from  the  extremities 
of  the  toes  nearly  to  the  knee  (Fig.  605).  The  turns  of  both  the 
plaster  and  the  flamiel  bandage  should  be  made  from  within,  doT*\m- 
ward  and  outward,  so  that  the  tension  aids  in  retaining  the  foot. 


TALIPES 


779 


__.;,         .         •««4»» Hrf-,  :,-*i^^^^^^ 

i 

Fig.  604. — Neglected  club-foot,  showing  the  secondary  knock-knee. 


Fig.  605. — The  first  application  of  the  plaster  bandage,  showing  the  improved  posi- 
tion.    (Compare  with  Fig.  599.) 


780  DEFORMITIES  OF   THE  FOOT 

^Mien  the  plaster  bandage,  which  during  the  hardening  process  has 
been  constantly  rubbed  and  manipulated  so  that  it  may  fit  the  part 
perfectly,  and  which  need  not  be  thicker  than  blotting  paper,  has 
become  firm,  a  long  stocking  is  drawn  over  it  and  is  attached  to  the 
body  clothing.  At  the  end  of  a  week  the  bandage  is  removed.  The 
leg  and  foot  are  gently  bathed  with  alcohol,  thoroughly  dried,  pow- 
dered, and  protected  as  before,  and  the  bandage  is  again  applied. 
At  this  second  dressing  the  irritable  adducting  muscles,  after  the 
interval  of  complete  rest,  will  be  much  less  active  and  the  contracted 
tissues  will  be  less  resistant,  so  that  the  foot  may  be  in  many 
instances  easily  turned  somewhat  outward  or  beyond  the  line  of 
the  leg.  If  for  any  reason  the  support  does  not  hold  its  position  a 
narrow  strip  of  adhesive  plaster  is  applied  to  the  outer  or  inner  sur- 
face of  the  leg,  its  lower  end  being  turned  back  and  incorporated  in 
the  plaster  bandage  which  is  then  fixed  in  position  by  direct  adhesion 
to  the  skin. 

After  four  or  five  applications  of  the  bandage,  at  weekly  intervals, 
the  foot,  in  ordinary  cases,  can  be  held  without  resistance  in  the 
attitude  of  extreme  eversion.  The  sole,  which  at  first  looked  back- 
ward, inward,  and  upward,  will  be  tm-ned  in  the  opposite  direction, 
forward,  outward,  and  downward,  and  the  imier  border  of  the  foot, 
which  was  concave,  is  now  convex  (Fig.  595) .  When  the  varus  has 
thus  been  overcorrected,  treatment  is  dhected  to  the  secondary 
equinus  which  has  been  aheady  partly  reduced.  At  first  one  carries 
the  foot  upward  (toward  dorsal  flexion),  while  it  is  still  retained  in 
the  abducted  position,  but  after  one  or  two  treatments,  when  the 
right-angled  attitude  has  been  attained,  it  is  brought  nearer  to  the 
axis  of  the  leg.  The  everted  position,  or  the  attitude  opposed  to 
varus,  is  retained,  however,  until  correction  is  comj^leted.  In  cor- 
recting the  equmus  a  certain  amount  of  force  may  be  required, 
sufficient  to  cause  some  discomfort  dm-ing  the  application  of  the 
plaster,  but  not  sufficient  to  occasion  suflering  afterward.  The  force 
is  applied  to  the  entu'c  foot,  so  that  the  posterior  extremity  of  the 
OS  calcis  may  be  drawn  downward  by  actual  lengthening  of  the 
tendo-Achillis,  and  not,  as  is  often  the  case,  by  an  overcorrection  of 
the  forefoot,  while  the  heel  remains  in  its  original  position  of  plantar 
flexion.  By  the  proper  application  of  force  the  equinus  is  gradually 
overcome;  the  sharp  indentation  or  fold  at  the  insertion  of  the 
tendo-Achillis  is  lessened,  and  the  heel  becomes  more  prominent. 

The  reduction  of  the  equinus  may  be  somewhat  more  difficult 
than  that  of  the  A'arus,  but  it  should  be  entirely  corrected  in  tlu-ee 
or  fom*  months  from  the  time  of  beginning  the  treatment.  As  has 
been  stated,  correction  of  the  deformity  implies  overcorrection 
(Fig.  594);  and  it  is  well,  when  this  has  been  attained,  to  hold  the 
foot  for  several  weeks,  by  means  of  the  plaster  bandage,  in  an 
attitude  of  extreme  eversion  and  dorsal  flexion  (calcaneovalgus) 
in  order  to  impress,  as  it  were,  the  new  position  upon  its  structure. 


TALIPES  781 

This  concludes  the  first  stage  of  the  treatment,  the  simple  rectifica- 
tion of  deformity. 

Correction  by  the  plaster  bandage  has  the  great  advantage  of 
placing  the  treatment  entirely  under  the  control  of  the  surgeon. 
The  application  even  in  resistant  cases  should  at  most  cause  but 
temporary  discomfort  and  usually  none  whatever.  The  support 
fits  perfectly :  it  is  light  and  clean,  and  it  holds  the  foot  in  the  desired 
attitude  without  undue  pressure. 

The  disadvantages  of  the  treatment  are  due  almost  entirely  to  its 
improper*application.  For  instance,  too  much  force  may  be  used  in 
correction  or  the  bandage  may  be  too  tight  or  too  heavy,  or  the 
padding  may  be  so  thick  that  it  does  not  retain  its  position.  Excori- 
ations are  usually  due  to  carelessness  in  the  application  of  the 
bandage,  or  because  it  is  not  removed  in  proper  season.  The  fear 
of  compression  or  of  atrophy  of  muscles  or  of  stunting  the  growth 
is  groundless.  At  the  end  of  the  treatment  the  corrected  foot  is, 
as  a  rule,  larger  than  one  that  has  remained  untreated.  The  stunted 
foot  is  the  result  of  non-treatment,  or  of  ineffective  treatment  by 
braces  or  otherwise,  not  of  the  temporary  rest  necessitated  by  the 
reduction  of  deformity. 

The  Rectification  of  Deformity  by  Splints  and  Braces. — Of  mechani- 
cal supports  there  are  many  varieties.  Complicated  appliances 
should  be  avoided  because  they  are  unnecessary  and  because  they 
serve  to  distract  attention  from  the  rapid  and  systematic  correction 
of  deformity.  Of  the  simpler  braces,  that  used  by  Judson  is  one  of 
the  best  and  will  serve  as  a  type  to  illustrate  this  form  of  treat- 
ment. The  method  of  application  may  be  described  in  Judson's  own 
words:  "The  apparatus  which  I  have  conveniently  used  to  effect 
this  reduction  before  the  child  learns  to  stand  is  a  simple  retentive 
brace  which  acts  as  a  lever,  making  pressure  on  the  outer  side  of  the 
foot  and  ankle  at  A,  in  Figs.  606  to  609,  inclusive,  and  counter- 
pressure  at  two  points,  one  on  the  inner  side  of  the  leg  at  B,  and  the 
other  at  the  inner  border  of  the  foot  at  C.  It  is  advisable  to  keep 
in  mind  that  this  simple  instrument  is  a  lever,  because  if  we  know 
that  we  are  using  a  lever  with  its  three  well-defined  points  of  pres- 
sure we  can  make  the  apparatus  more  efficient  than  if  we  view  it, 
in  a  more  general  way,  as  an  apparatus  for  giving  a  better  shape  to 
the  foot. 

"I  use  a  little  brace  made  of  sheet  brass,  doing  the  work  with  a 
few  simple  tools.  An  advantage  of  doing  the  work  one's  self  is  that 
there  is  no  room  for  doubt  as  to  where  the  blame  lies  if  the  apparatus 
does  not  work  well.  Two  curved  disks,  B  and  C,  Figs.  608  and  609, 
are  riveted  to  a  shank,  D,  and  thus  is  formed  that  part  of  the  brace 
which  applies  the  two  points  of  counter-pressure;  while,  on  the  other 
hand,  the  point  of  pressure  is  brought  into  action  by  a  third  disk  or 
shield,  A,  which  is  drawn  tightly  against  the  outer  side  of  the  foot 
and  ankle  and  held  in  place  by  a  strip  of  adhesive  plaster,  E,  which 


782 


DEFORMITIES  OF   THE  FOOT 


includes  the  leg  and  the  piece  which  connects  the  two  disks,  B  and 
C.  The  disks  are  lined  with  two  or  three  thicknesses  of  blanket, 
easily  renewed,  when  necessary,  with  a  needle  and  thread.  These 
braces  are  so  cheap  and  easily  knocked  together  that  it  is  nothing 
to  apply  new  and  larger  ones,  using  heavier  material  for  the  shank 
as  the  child  grows.  In  general,  three  sizes  will  be  enough,  the  shanks 
being  12-gauge,  f  in.  wide;  14-gauge,  |  in.  wide;  and  16-gauge,  f  in. 
wide.  The  disks  are  conveniently  made  from  22-gauge,  \\  in.  wide. 
The  rivets  are  copper  belt-rivets.  No.  13.  A  lip  turned  on  the  edges 
of  the  disks,  with  the  flat  pliers,  gives  stiffness  to  the  thin  brass  and 
protects  the  skin  from  the  rough  edge.  If  more  easily  obtained,  tin 
disks,  light  bars  of  iron  or  steel,  and  ordinary  iron  rivets  would 
doubtless  answer. 


B^- 


FiG.  606 


Fig.  607 


Fig.  608 


Fig.  609 


Fig.  610        Fig.  611  Fig.  612  Fig.  613 

Figs.  606  to  613. — The  Judson  club-foot  splint  and  its  application. 


"The  brace  is  applied  with  three  strips  of  adhesive  plaster.  The 
upper  and  lower  pieces,  E  and  G,  Fig.  609,  are  simply  to  keep  the 
apparatus  in  place,  which  they  do  effectively  if  ordinary  gum  plaster 
is  used;  while  by  drawing  the  middle  strip,  E,  tightly  over  the  shield, 
and  straightening  the  brace  from  time  to  time,  the  deformity  is 
gradually  and  gently  reduced.  At  each  reapplication  the  brace  is 
made  a  little  straighter  than  the  foot  at  that  stage.  This  may 
readily  be  done  by  the  hands,  and  then  the  adhesive  strip  is  to 
be  tightened  oxev  the  shield  until  the  shape  of  the  foot  agrees  with 
that  of  the  brace.  After  a  few  days  the  brace  is  to  be  made  still 
straighter  and  again  reapplied,  and  made  tight  until  another  point 


TALIPES  783 

of  improvement  is  gained.  The  brace  is  applied  very  crooked  at  the 
beginning  of  treatment,  as  in  Figs.  608  and  609,  and  is  straightened 
from  time  to  time,  and  a  longer  brace  applied  as  the  deformity  is 
reduced  and  the  patient  grows. 

"By  this  simple  and  prosy  treatment,  carried  out  systematically 
and  without  haste,  or  violence  or  pain,  the  foot,  unless  it  is  a  frightful 
exception,  may  with  certainty  be  changed  from  varus  to  valgus. 
At  the  same  time  the  tendo-Achillis  is  lengthened  until  the  position 
of  the  foot  is  near  the  normal,  or  at  right  angles  with  the  leg,  as  the 
result  of^manipulation  and  giving  the  brace  from  time  to  time  a 
partly  anteroposterior  action.  Figs.  608  and  609  show  approxi- 
mately the  shape  of  the  brace  at  the  beginning  of  treatment;  Figs. 
610  and  611  when  the  varus  is  reduced,  and  Figs.  612  and  613  when 
valgus  has  taken  the  place  of  varus.  The  foot,  in  this  latter  stage, 
may  not  hold  itself  when  left  to  itself,  but  with  almost  no  force  and 
with  one  finger  it  may  be  pushed  into  valgus." 

When  the  varus  deformity  is  reduced  the  equinus  is  gradually 
corrected  by  carrying  the  splint  behind  the  internal  malleolus; 
and,  finally,  if  necessary,  direct  upward  pressure  may  be  applied 
by  lengthening  the  brace  and  applying  it  to  the  posterior  aspect  of 
the  foot  and  leg.  It  may  be  noted  that  manipulation  and  stretch- 
ing the  contracted  parts  when  the  brace  is  removed  is  of  much 
importance  in  the  correction  of  deformity  by  this  or  other  means. 
Splints  of  wood,  tin,  felt,  and  the  like  may  be  employed,  but  they 
present  no  particular  advantage  over  that  which  has  been  described. 

Tenotomy. — The  equinus  has  been  spoken  as  of  secondary  impor- 
tance, although  its  complete  correction  by  mechanical  means  may  be 
more  difficult  than  that  of  varus.  When  this  deformity  is  especially 
resistant,  as  in  late  infancy,  time  will  be  gained,  after  the  foot  has 
been  forced  into  the  position  of  equinovalgus,  by  the  division  of  the 
tendo-Achillis.  This  is  the  most  resistant  of  the  shortened  tissues, 
but  even  after  its  division  it  may  be  necessary  to  use  considerable 
force  to  stretch  the  other  contracted  parts  that  limit  extreme  dorsal 
flexion.  The  chief  obstacle  in  resistant  cases  is  the  posterior  liga- 
ment of  the  ankle,  and  it  is  often  advisable  to  divide  this  structure, 
in  part  at  least,  so  that  it  will  give  way  under  manipulation.  When 
the  fcot  has  been  forced  into  the  position  of  overcorrection  it  is 
fixed  in  a  plaster  bandage  for  several  weeks,  until  the  interval 
between  the  separated  ends  of  the  tendon  is  filled  in  with  the  new 
tissue. 

In  some  instances  the  leg  is  rotated  inward  upon  the  thigh,  and 
the  habitual  attitude  is  accompanied  by  accommodative  changes 
in  the  ligaments  of  the  knee-joint.  During  the  treatment  of  the 
club-foot  this  secondary  distortion  may  be,  in  part  at  least,  corrected 
by  forcible  manual  rotation  of  the  leg  outward  on  the  thigh  several 
times  daily.  If  the  leg  is  slightly  bowed  it  may  be  corrected  in 
the  same  manner. 


784 


DEFORMITIES  OF   THE  FOOT 


The  Second  Stage  of  Treatment. — Support  and  Restoration  of  Func- 
tion.— When  the  deformed  foot  has  been  corrected,  in  the  sense  that 
normal  movement  in  all  directions  is  no  longer  restricted,  the  first 
and  most  difficult  part  of  the  treatment  will  have  been  completed. 
But  although  the  foot  may  be  normal  in  appearance,  its  muscular 
balance  has  not  been  restored.  This  is  shown  by  the  fact  that  when 
support  is  removed  the  foot  usually  hangs  downward  and  inward, 
and  there  is  little  apparent  power  in  the  dorsiflexors  and  abductors 
to  draw  it  upward  and  outward.  If  at  this  stage  treatment  were 
abandoned,  the  deformity  would  inevitably  recur,  at  least  in  part. 
For  this  reason  the  foot  must  be  supported  in  proper  position  until 
the  slack  of  the  lengthened  tissues  has  been  taken  up  by  devel- 
opment in  the  normal  attitude,  a  de\'elopment  that  may  be  aided 
by  massage  and  other  forms  of  stimulation  of  the  muscles.  Prac- 
tically, support  is  always  necessary  until  the  child  has  begun  to 
walk. 


Fig.   614. — The  adhesive-plaster  support  as  used  after  correction  of  the  deformity. 


Retention  by  Adhesive  Plaster. — In  those  cases  of  the  milder  t^-pe, 
in  which  the  deformity  has  been  easily  and  quickly  corrected,  tem- 
porary support  only  is  indicated,  and  for  this  purpose  adliesive 
plaster  will  often  serve.  A  narrow  strip  is  first  carried  about  the 
forefoot,  to  it  a  longer  band  is  fixed  and  is  carried  up  the  outer  side 
of  the  leg  to  the  knee  where  it  is  held  in  place  by  an  encircling  band. 
This  is  applied  with  sufficient  tension  to  hold  the  foot  in  abduction 
and  dorsal  flexion.  The  nurse  is  then  instructed  to  push  the  foot 
up  to  the  extreme  limit  many  times  during  the  day.  She  is  taught 
also  to  apply  the  dressing  properly.  This  support  is  used  until 
normal  motion  has  been  regamed. 

The  Retention  Brace. — ^The  form  of  retention  brace  will  vary  some- 
what according  to  the  indications  of  the  individual  case.  The  object 
is  to  hold  the  foot  in  what  is  called  the  overcorrected  attitude — that 


TALIPES 


785 


is,  dorsiflexion  and  eversion.  This  may  consist  of  a  calf  pad  and 
foot  plate  with  an  internal  flange  (Fig.  615)  of  aluminum  joined 
to  one  another  by  a  thin  steel  bar  shaped 
to  the  heel.  The  brace  is  held  in  place 
by  adhesive  plaster  and  may  be  removed 
at  intervals  for  massage  and  exercise  by 
the  mother.  One  of  the  most  efficient 
supports  for  older  children  is  the  Taylor 
brace  (Fig.  61 6) .  This  consists  essentially 
of  a  light  upright  that  extends  along  the 
inner  side  of  the  leg  to  the  knee,  and  a 
thin  steel  foot  plate  of  the  exact  size  of 
the  sole,  with  an  upright  flange  on  the 
inner  side,  rising  to  a  point  just  above 
the  dorsal  surface  of  the  foot,  against 
which  the  foot  is  pressed  closely,  so 
that  recurrence  of  the  varus  deformity 
is  prevented.  The  joint  at  the  ankle 
is  provided  with  a  catch  that  pre- 
vents plantar  flexion,  but  permits  dorsiflexion.  By  bending  the 
upright  and  the  sole  plate  the  foot  may  be  held  in  slight  eversion. 


Fig. 


615. — A  retention  brace 
used  in  infancy. 


Fig.  616.— The  Taylor  club-foot  brace.     ' 

The  apparatus  is  applied  with  straps,  as  illustrated,  and  if  neces- 
sary it  is  made  more  secure  by  a  band  of  adhesive  plaster,  applied 
50 


786 


DEFORMITIES  OF  THE  FOOT 


on  the  inner  side  of  the  leg  to  hold  the  heel  firmly  against  the  foot 
plate.     The  foot  is  thus  held  constantly  at  a  right  angle  to  the  leg, 


Fig.  617  Fig.  618 

Figs.  617  and  618. — Taylor  club-foot  brace,  showing  the  method  of  application  and 

attachment. 


Fig.  619  Fig.  620 

Figs.  619  and  620. — The  Taylor  club-foot  brace,  showing  the  adhesive  plaster,  by 
means  of  which  the  heel  is  held  down,  and  the  method  of  attachment.  This  brace 
was  used  by  Taylor  to  correct  deformity  as  well  as  to  retain  the  foot  in  proper  position, 
as  is  illustrated  by  these  figures.  As  a  retention  apparatus  the  foot  plate  should  be 
held  at  a  right  angle  to  the  upright  by  the  stop-joint  shown  in  Fig.  616. 


TALIPES  787 

or,  better,  in  the  early  stage  of  treatment,  in  an  attitude  of  dorsi- 
flexion  and  valgus. 

Occasionally,  after  complete  rectification  of  the  deformity,  the 
foot  still  turns  in.  In  most  instances  this  is  due  to  an  inward  rota- 
tion of  the  tibia  on  the  femur  at  the  knee-joint,  but  in  some  cases  it 
is  caused  by  a  spiral  twist  of  the  tibia  itself.  In  order  to  correct  this 
secondary  deformity  an  extension  of  the  upright  of  the  brace  is 
carried  beneath  the  leg,  provided  with  a  joint  at  the  knee,  and  is 
extended  up  the  outer  side  of  the  thigh.  At  the  hip  it  is  attached 
by  a  free  joint  to  a  padded  pelvic  band  of  light  steel  (Fig.  627). 
The  band  holds  the  upright  in  the  proper  relation  to  the  thigh; 
thus,  by  twisting  the  part  below  the  knee  the  foot  can  be  rotated 
outward  to  the  desired  degree.  In  less  marked  cases  the  retention 
bands  used  for  pigeon-toe  may  be  employed  (Fig.  575). 

Methodical  Manual  Correction. — Several  times  during  the  day  the 
brace  should  be  removed  in  order  that  the  foot  may  be  thoroughly 
massaged  and  forcibly  turned,  first  toward  valgus — that  is,  outward 
at  the  mediotarsal  joint — so  that  the  inner  border  is  made  convex, 
and  then  to  the  extreme  limit  of  dorsiflexion  and  abduction.  If  the 
leg  is  rotated  inward  it  is  forcibly  rotated  outward  on  the  femur.  Even 
if  the  tibia  is  actually  twisted  on  its  long  axis,  the  influence  of  the 
brace  and  forcible  manipulation  will  usually  correct  the  deformity. 
Active  contractions  of  the  weak  muscles  may  be  induced  by  tickling 
the  sole  of  the  foot  or  by  the  use  of  electricity,  and,  finally,  the  entire 
limb  should  be  thoroughly  massaged  before  the  brace  is  reapplied. 

When  the  deformity  shows  no  tendency  to  recur  the  brace  may 
be  removed  for  a  part  of  a  day;  later  it  is  used  only  at  night;  and, 
finally,  it  may  be  discarded  if  the  child  walks  normally.  But  it  is 
best  to  continue  the  daily  manipulation,  more  particularly  the 
systematic  stretching  or  overcorrection  of  the  foot,  for  a  long  time. 
Thus  one  may  assure  one's  self  that  there  is  no  tendency  toward 
deformity,  of  which  the  first  symptom  is  always  a  slight  limitation 
of  dorsal  flexion  and  of  abduction. 

In  many  instances  the  deformity  may  have  been  so  thoroughly 
overcorrected  and  the  after-treatment  of  massage  and  stretching 
may  have  been  so  efficiently  applied  by  the  nurse  or  parent  during 
infancy  that  the  retention  brace  may  be  unnecessary  when  the 
child  begins  to  walk.  On  the  other  hand,  the  inclination  toward 
deformity  may  be  so  marked  that  a  brace  may  be  necessary  to  hold 
the  foot  in  slight  abduction  and  valgus  for  a  year  or  longer.  In 
other  cases  the  use  of  a  light  brace  to  hold  the  foot  in  the  over- 
corrected  position  during  the  night  is  alone  required.  These  are 
points  to  be  decided  by  the  circumstances  in  each  case.  The  period 
of  observation  and  supervision  is  included  in  the  final  stage  of  the 
treatment. 

Third  Stage  of  Treatment  Supervision. — During  this  period  the 
attitudes  of  the  limb  and  foot  of  the  walking  child  must  be  carefully 


788  DEFORMITIES  OF   THE  FOOT 

watched,  and  particularly  the  signs  of  wear  on  the  sole  of  the  shoe. 
If  it  shows  greater  wear  on  the  outer  side  than  is  usual  it  is  an  indi- 
cation that  the  weight  does  not  fall  directly  on  the  centre  of  the  foot 
and  that  there  is,  therefore,  a  tendency  toward  deformity.  This 
must  be  counteracted  by  making  the  sole  thicker  on  the  outer  side 
or  slightly  wedge-shaped,  so  that  the  weight  may  be  deflected  toward 
the  inner  border. 

This  third  period  of  treatment,  or,  rather,  of  oversight  of  the 
functional  use  of  the  foot,  must  be  continued  indefinitely.  In  fact, 
it  is  the  quality  of  this  final  supervision  that  decides  in  most 
instances  whether  the  ultimate  outcome  is  to  be  what  is  called  a 
satisfactory  result  or  a  perfect  anatomical  and  functional  cure. 

The  Treatment  of  Neglected  Club-foot. — The  treatment  of  club- 
foot, under  what  may  be  called  the  proper  conditions,  as  outlined 
in  the  preceding  pages,  applies  practically  to  all  cases  before  the 
completion  of  the  first  year  of  life,  and  mechanical  rectification  may 
be  successfully  employed  in  cases  far  beyond  this  limit  of  age.  As 
a  rule,  however,  when  the  patient  has  walked  for  any  length  of  time, 
the  resistance  of  the  tissues  has  increased  to  such  an  extent  that 
more  rapid  and  effective  treatment  is  indicated.  The  investiga- 
tions of  Wolff  have  shown  that  the  internal  structure  of  the  bones 
corresponds  to  their  external  contour,  and  that  the  structure  and 
contour  are  adaptations  to  functional  use.  This  internal  structure 
is  not,  however,  permanent,  but  is  readily  transformed  to  conform 
to  changes  of  function.  If,  then,  the  external  contour  of  the  club- 
foot were  suddenly  reversed,  and  if  the  foot  were  used  in  this  new 
attitude,  a  transformation  of  the  internal  structure  of  the  bones 
and  at  the  same  time  of  their  shape  would  begin  at  once.  This 
would  continue  until  both  structure  and  shape  had  become  adapted 
to  habitual  function.  It  is  upon  this  natural  power  of  transforma- 
tion that  one  depends  for  the  final  and  complete  change  of  the 
distorted  bones  to  the  normal;  and  what  is  true  of  a  resistant 
structure  like  bone  is  equally  true  of  the  other  constituents  of  the 
deformed  foot. 

Age  as  Influencing  Treatment. — There  is,  then,  this  important 
difference  between  the  indications  for  treatment  in  infancy  and  in 
childhood.  In  the  first  instance  the  foot  has  no  essential  function; 
in  the  second  the  weight  of  the  body  and  habitual  use  tend  to  con- 
firm and  to  increase  the  deformity.  If  walking  is  permitted  during 
the  process  of  rectification  of  the  foot  it  must  necessarily  retard 
its  progress.  As  a  general  principle  of  treatment,  functional  use 
should  not  be  permitted,  therefore,  until  the  weight  of  the  body  may 
aid  rather  than  retard  the  correction  of  deformity.  The  compli- 
cated and  cumbersome  machines  that  are  described  in  the  older 
text-books  were  designed  for  the  ambulatory  treatment  of  club- 
foot. The  most  important  function  of  the  brace,  aside  from  its 
use  as  a  corrective  appliance  in  early  infancy,  is  to  support  the  foot 


TALIPES 


789 


after  deformity  has  been  corrected  and  to  guide  it  in  its  functional 
use  until  its  normal  strength  has  been  regained.  And  while  recti- 
fication of  deformity,  even  in  adolescence,  by  simple  mechanical 
means  alone  is  possible,  yet  only  in  exceptional  cases  would  one  be 
justified  in  selecting  a  tedious  and  uncertain  treatment  which  offers 
practically  no  advantage  overi  more  rapid  methods. 

The  Rapid  Correction  of  Deformity. — The  principles  on  which 
operative  treatment  should  be  conducted  are  the  same  that  govern 
mechanical  treatment.  Thus  the  deformed  foot  must  be  over- 
corrected,  and  it  must  be  fixed  in  the  overcorrected  position  until 
the  immediate  tendency  toward  deformity  has  been  overcome.     It 


y 


^ 


^..'-^^'grx^-'  ^,        ^M 


Fig.  621. — Reduction  of  the  varus  deformity.     (Lorenz.) 

must  then  be  supported  until  the  process  of  transformation  of  its 
internal  structure  is  completed  and  until  the  balance  of  muscular 
power  has  been  regained.  No  surgical  operation,  however  radical, 
can  be,  in  childhood  at  least,  curative  by  itself  alone.  Operative 
procedures  are  undertaken  simply  for  the  purpose  of  accomplishing 
the  primary  overcorrection,  and  the  operation  by  which  this  object 
can  be  attained  with  the  least  interference  with  the  structure  of  the 
foot  should  be  selected.  Such  an  operation  is  what  may  be  called 
forcible  manual  correction. 

Forcible  Manual  Correction. — The  patient  having  been  anesthe- 
tized, one  first  attempts  to  correct  the  sharp  inward  twist  at  the 
mediotarsal  joint.     Supposing  the  left  foot  to  be  deformed,  one 


790 


DEFORMITIES  OF   THE  FOOT 


grasps  the  heel  with  the  right  hand  in  such  ii  manner  that  the  pro- 
-jection  or  muscular  part  of  the  palm  lies  on  the  outer  aspect  of  the 
foot  against  the  most  prominent  part  of  its  outer  border,  ^Yhich  is  at 
the  junction  of  the  os  calcis  and  cuboid  bones.  This  hand  serves  as  a 
fulcrum  over  which  the  inverted  foot  may  be  bent.  The  forefoot 
is  then  grasped  firmly  by  the  left  hand,  and  one  begins  a  series  of 
outward  twists  over  the  fulcrum  of  the  opposing  palm,  gently  at 
first,  with  alternate  relaxation  of  pressure,  but  with  gradually 
increasing  force  as  the  resistant  tissues  stretch  under  the  tension. 


Fig.  622. — Flattening  the  sole.      (Lorenz.) 

If  greater  force  is  required,  a  triangular  block  of  wood,  well 
padded,  may  be  used  as  the  fulcrum  (Fig.  621),  one  hand  pressing 
on  the  heel  and  the  other  on  the  forefoot;  but  there  is  a  great  advan- 
tage in  using  nothing  but  the  hands,  because  one  feels  that  no  injuri- 
ous force  is  likely  to  be  exerted.  Under  this  steady  manipulation 
the  foot  soon  loses  its  rigidity  and  its  elastic  recoil  toward  deformity; 
it  becomes  so  limp  that  with  two  fingers  one  cannot  only  hold  the 
sole  straight,  but  can  push  it  or  bend  it  outward.  This  completes 
the  first  stage  of  the  niethodical  correction. 

One  then  turns  his  attention  to  the  inversion  of  the  sole,  which 
makes  the  outer  border  of  the  foot  lower  than  the  inner  border. 
The  leg  is  grasped  firmly  near  the  ankle  with  the  left  hand,  and 


TALIPES 


791 


with  the  right  the  foot  is  forcibly  twisted  in  a  direction  downward, 
outward,  and  upward,  over  and  over  again,  with  steadily  increasing 
force  as  the  tissues  slowly  yield,  until  it  may  be  forced  into  a  position 
of  extreme  abduction,  so  that  the  sole  may  be  made  to  look  outward 
and  downward — the  reverse  of  the  former  attitude. 

One  next  stretches  the  contracted  plantar  fascia  and  reduces  the 
cavus  which  is  usually  present  by  forcing  the  forefoot  toward  dorsi- 
flexion,  against  the  resistance  of  the  contracted  tendo-Achillis, 
until  the  sole  is  made  perfectly  flat  (Fig.  622).  Finally,  the  fourth, 
and  often  ihe  most  difficult  part  of  the  rectification — that  of  forcing 
the  displaced  astragalus  into  its  proper  position  between  the  mal- 


FiG.  623. — Reduction  of  the  equinas  deformity.     (Lorenz.) 

leoli — is  attempted.  To  accomplish  this  the  tendo-Achillis  is  first 
divided  subcutaneously,  and,  if  necessary,  the  posterior  ligament  of 
the  ankle  also.  The  patient  is  then  turned  upon  his  face  so  that 
with  the  knee  resting  on  the  table  the  leg  is  held  upright.  This 
allows  one  to  hook  the  fingers  about  the  extremity  of  the  os  calcis, 
while  the  hand  and  arm,  lying  along  the  sole  of  the  foot,  may  be 
used  as  a  lever  to  force  it  toward  dorsal  flexion  as  the  os  calcis  is 
drawn  downward.  In  this  manner  forcible  stretching  is  continued 
until  the  dorsum  of  the  foot  can  be  brought  almost  into  apposition 
with  the  crest  of  the  tibia.  When  the  operation  has  been  completed 
the  foot  should  be  perfectly  limp.     It  is  usually  somewhat  congested 


792  DEFORMITIES  OF   THE  FOOT 

from  the  pressure  of  the  fingers,  but  it  is  warm  and  the  circulation 
is  unimpaired. 

One  may  assume  that  in  the  transformation  of  rigid  deformity 
to  yielding  tissues  that  can  be  moulded  into  the  desired  shape,  the 
component  parts  of  the  deformed  foot  must  have  been  subjected  to 
considerable  violence;  that  ligaments  and  muscles  must  have  been 
stretched  and,  it  may  be,  ruptured;  that  new  surfaces  are  now 
apposed  to  one  another  in  the  articulations,  and  that  the  bones  have 
been  forced  into  approximately  normal  position.  This  method  of 
treatment  has  a  great  advangtage  over  the  ordinary  operative 
treatment  in  that  the  entire  foot  participates  in  the  correction  instead 


Fig.  624. — Untreated  club-foot,  showing  the  secondary  knock-knee.    (See  Fig.  625.) 

of  a  limited  portion,  as  wdien,  for  example,  bone  is  removed  by  cunei- 
form osteotomy.  It  has  a  second  and  almost  equally  important 
advantage  in  that  the  immediate  use  of  the  corrected  and  yielding 
foot  is  possible  in  the  place  of  the  rest  that  must  follow  cutting 
operations.  For  these  reasons  it  should  be  the  operation  of  choice, 
and  preliminary,  at  least,  to  more  severe  procedures  in  the 
treatment  of  resistant  club-foot  in  childhood.  The  only  disadvan- 
tage of  the  operation  is  the  actual  labor  which  it  necessitates  on  the 
part  of  the  surgeon,  usually  twenty  minutes  or  more  of  rather 
exhausting  work. 

The  foot  must  now  be  fixed  by  a  plaster  splint  in  an  overcorrected 
position..    It  is  first  evenly  covered  with  a  layer  of  sheet  wadding. 


TALIPES 


79^ 


tliick  bands  of  which  are  inserted  between  the  toes,  and  while  it  is 
held  by  the  assistant  in  the  overcorrected  position  the  plaster  ban- 
dages are  applied  from  the  tips  of  the  toes  to  the  upper  part  of  the 
thigh.  It  is  important  that  the  toes  should  not  project  beyond  the 
bandage  because  of  the  swelling  that  sometimes  follows.  It  is 
important,  also,  that  the  foot  should  be  held  in  the  proper  position 
while  the  bandage  is  hardening,  and  that  it  should  not  be  manipu- 
lated to  any  extent  after  the  bandage  is  applied,  in  order  that  no  pro- 
jecting wfinkle  may  press  against  the  skin.  The  bandage  is  applied 
above  the  knee  in  order  that  the  tibia  may  be  rotated  outward  to 


Fig.  625. — After    forcible    correction. 
Compare  with  Fig.  624. 


Fig.  626. — The  attitude  of  overcorrec- 
tion, in  which  the  feet  are  fixed  after  the 
operative  treatment,  the  plaster  bandage 
extending  only  to  the  knees. 


its  normal  position  and  held  there,  and  because  more  effective  fixa- 
tion may  be  assured  and  greater  pressure  exerted  on  the  foot  in 
walking.  To  utilize  this  pressure  to  better  advantage  the  bandage 
should  be  made  very  thick  beneath  the  sole,  or  a  thin  foot  plate  of 
wood  may  be  incorporated  in  the  plaster  if  care  is  taken  to  prevent 
pressure  on  sensitive  points.  When  the  bandage  is  applied  the  foot 
should  be  flexed  beyond  the  right  angle,  twisted  far  outward,  and 
the  outer  border  should  be  elevated  considerably  beyond  the  level 
of  the  inner  border  (Fig.  625). 

One  would  suppose  that  much  pain  and  swelling  would  follow  the 
operation.     This  is,  however,  not  usually  the  case.     Often,  on  the 


794 


DEFORMITIES  OF   THE  FOOT 


following  day,  the  patients  are  able  to  stand  upon  the  foot,  and 
always  within  the  first  week  if  the  support  has  been  properly 
applied.  The  pain  following  this  operation  is  far  more  often  caused 
by  pressure  of  an  ill-fitting  bandage  than  by  the  violence  that  has 
been  used.  Thus  one  should  be  careful  to  remove  sections  of  the 
splint  if  it  appears  to  cause  undue  discomfort.     These  points  are 

usually  the  front  of  the  ankle,  the 
back  of  the  heel,  and  the  inner 
border  of  the  great  toe.        * 

The  Importance  of  Functional  Use. — 
The  immediate  use  of  the  foot  is  en- 
couraged, in  order  that  the  weight 
of  the  body  falling  on  its  yielding 
structure  may  still  further  correct  the 
deformity.  Although  only  the  heel 
and  inner  border  bear  weight  directly, 
yet  the  pressure  of  the  plaster  sole  on 
the  parts  that  do  not  come  in  contact 
with  the  floor  is  usually  sufficient  to 
mould  the  foot  into  its  proper  shape. 
If  greater  pressure  is  thought  to  be 
necessary,  wedges  of  wood  or  cork 
may  be  attached  to  the  sole  of  the 
plaster  bandage,  to  equalize  the  bear- 
ing surface.  The  support  is  covered 
by  a  stocking;  a  slipper  may  be  worn 
indoors  and  an  ordinary  overshoe  for 
street  wear. 

The  first  splint  should  be  removed 
at  the  end  of  about  four  weeks,  as 
it  will  have  become  loose.  The  foot 
will  then  be  found  to  be  extremely 
flexible,  and  by  an  enthusiast  it  might 
be  considered  cured;  but  knowledge 
of  its  previous  condition  should  make 
it  evident  that  a  much  longer  time 
will  be  necessary  for  its  consolidation 
in  the  new  position.  At  this  time  al- 
most no  evidence  of  the  operation  remains  except,  it  may  be,  slight 
discoloration  of  the  skin.  The  foot  is  again  held  as  far  as  possible  in 
the  overcorrected  position  and  another  plaster  bandage  is  applied, 
usually  as  far  as  the  knee  only.  This  remains  for  from  six  weeks  to 
six  months,  according  to  the  character  of  the  deformity  and  quality 
of  the  after-treatment,  it  being  apparent,  of  coiuse,  that  the  longer 
the  foot  is  fixed  in  the  overcorrected  position  the  less  danger  of 
subsequent  relapse.  The  patient  uses  the  foot  constantly  and  is 
drilled  in  the  proper  method  of  walking,  so  that  the  muscles  of 
the  limbs  may  become  adapted  to  normal  attitudes. 


Fig.  627.— The  Taylor  club-foot 
brace,  with  pehdc  band,  to  prevent 
inward  rotation  of  the  leg.  The 
brace  is  shown  before  the  covering 
and  straps  are  applied. 


TALIPES  795 

In  most  instances  the  plaster  bandage  is  replaced,  at  the  end  of 
about  three  months,  by  a  brace  to  be  worn  inside  the  shoe,  usually 
of  the  simplest  description  (Fig.  644),  consisting  of  an  upright  bar 
with  a  calf  band,  either  fixed  to  a  sole-plate  or  attached  by  a  joint 
that  will  permit  dorsal  flexion  but  checks  extension  at  a  right  angle. 
This  is  applied  because  the  dorsal  flexors,  after  years  of  disuse,  only 
slowly  recover  sufficient  power  to  resist  the  action  of  the  opposing 
group  and  the  influence  of  gravity. 

The  second  stage  of  the  treatment  is  now  begun.  This  may  be 
divided  into  a  period  of  active  treatment  and  one  of  supervision. 
The  first,  or  treatment-stage,  consists  in  massage  of  the  entire  leg 
and  of  the  foot  to  stimulate  the  growth  of  the  atrophied  muscles, 
and  methodical  manipulation  of  the  foot  several  times  a  day.  The 
important  point  in  this  manipulation  is  to  force  the  foot  with  the 
hand  to  the  extreme  limit  of  the  range  of  motions  possible  immedi- 
ately after  the  operation,  viz.,  eversion,  abduction,  and  dorsal 
flexion,  in  the  same  order  as  at  the  time  of  operation.  At  the  same 
time  the  patient  attempts  voluntarily  to  carry  out  these  motions 
with  his  own  muscles,  the  power  being  supplied  by  the  hand  of  the 
manipulator.  Slowly  the  muscles  gain  in  strength  and  ability,  and 
when  normal  muscular  power  and  balance  have  been  regained,  the 
patient  is  practically  cured.  But  for  a  long  period  supervision  of 
the  patient's  attitude,  of  the  manner  of  using  the  foot,  of  the  wear 
of  the  sole  of  the  shoe  and  the  like  must  be  exercised  if  one  aims 
to  restore  its  normal  appearance  and  function. 

One  cannot  exaggerate  the  importance  of  this  after-treatment, 
and  of  supervision  at  least  on  the  part  of  the  surgeon.  The  active 
treatment  may  often  be  left  to  the  parents.  But  constant  oversight 
is  necessary  to  make  this  after-treatment,  which  seems  so  common- 
place and  simple,  effective,  and  to  assure  one's  self  that  the  range 
of  motion  regained  by  the  operation  does  not  gradually  become  more 
and  more  restricted,  even  though  the  contour  of  the  foot  appears  to 
be  normal.  Forcible  manual  correction  may  be  employed  with  advan- 
tage from  the  second  to  the  tenth  year,  although  the  limits  may  be 
extended  in  either  direction  in  special  cases.  In  this  operation,  as 
described,  the  tendo-Achillis  is  the  only  structure  divided.  There  is 
no  particular  objection  to  subcutaneous  division  of  other  tendons 
or  ligaments  in  connection  with  forcible  manual  correction;  but  for 
such  prolonged  manipulation  it  is  much  better  if  the  skin,  which 
itself  must  be  stretched,  is  unbroken  and  dry  rather  than  moist 
from  the  bleeding  from  punctured  wounds.  For  this  reason  it  is 
well  to  correct  the  deformity  without  tenotomy  if  possible.^  In  more 
resistant  cases  overcorrection  may  require  two  or  more  operations. 

1  Forcible  manual  correction  appears  to  have  been  described  first  by  Delore. 
Lorenz  employs  the  method  supplemented  in  the  older  cases  by  the  use  of  his  osteo- 
clast, to  the  exclusion,  practically,  of  all  other  treatment.  (Heilung  des  Klumpfusses 
durch  das  modellirende  Redressement,  Wiener  Klinik,  November,  1895.)  For  this 
reason  it  is  sometimes  called  the  Lorenz  treatment.  The  method  that  has  been 
described  has  been  employed  by  the  author  for  many  years. 


796  DEFORMITIES  OF   THE  FOOT 

SUPPLEMENTAL  OPERATIONS. 

If  forcible  manipulation  is  not  suflScient  for  the  complete  over- 
correction of  the  deformity,  division  of  the  resistant  tissues  is 
indicated.  Of  these  the  most  important  are  the  posterior  calcaneo- 
tibial, the  deltoid  and  the  superior  and  inferior  calcaneoscaphoid 
ligaments.  An  incision  is  made  from  a  point  above  and  behind  the 
internal  malleolus  and  is  carried  forward  below  its  extremity  to  the 
navicular. 

Ober,  of  Boston,  has  suggested  that  the  deltoid,  the  most  impor- 
tant of  the  ligaments  be  divided  b}'  an  incision  convex  upward 
tliree-fourths  of  an  inch  above  the  tip  of  the  malleolus  that  it  be 
dissected  from  the  bone  and  displaced  downward  as  the  foot  is  cor- 
rected. Through  this  incision  all  resistant  parts  are  divided 
including,  in  addition  to  the  ligaments  specified,  the  tendo-Achillis 
and  the  plantar  fascia  if  necessary,  so  that  the  astragulus  and  os 
calcis  may  be  placed  in  the  attitude  of  valgus. 

Malleotomy. — In  confirmed  club-foot,  of  the  t;^^e  under  con- 
sideration, the  chief  obstacle  to  perfect  correction  is  often  the 
astragalus.  This  is  displaced  forward,  downward,  and  inward, 
only  the  posterior  portion  of  its  articulating  surface  being  contained 
between  the  malleoli.  Thus  the  space  between  the  two  bones  may 
have  become  insufficient  for  the  anterior  and  wider  part  of  the  body 
of  the  astragalus.  In  such  cases,  even  after  division  of  the  tendo- 
Achillis  and  the  ligaments  of  the  ankle,  dorsal  flexion  still  remains 
restricted,  and  examination  shows  that  the  astragalus  still  projects 
as  before,  even  though  the  foot  has  been  forced  into  a  position 
of  apparent  dorsiflexion  and  abduction.  This  apparent  correction 
is  the  result  of  overcorrection  at  the  mediotarsal  joint,  of  outward 
rotation  of  the  tibia  upon  the  femur,  and  of  backward  displacement 
of  the  fibula. 

In  such  instances  the  malleoli  may  be  separated  from  one  another 
by  dividing  the  ligaments  that  hold  them  in  apposition.  iVn  incision 
is  made  downward  along  the  anterior  border  of  the  external  malleo- 
lus and  forward  to  expose  the  astragalus.  The  ligaments  binding 
the  tibia  and  fibula  to  one  another  are  separated  and  they  are  pried 
apart  to  provide  sufficient  space.  Other  resistant  tissues  are  divided 
if  necessary  and  if  the  neck  of  the  astragalus  is  deformed  it  may  be 
corrected  by  a  linear  or  cuneiforn  osteotomy.  The  wound  is  then 
closed  and  the  foot  held  in  the  overcorrected  position  by  a  plaster 
bandage.  This  should  be  extended  to  the  thigh,  the  knee  being 
flexed  to  assure  better  fixation. 

Secondary  Deformities. — In  cases  such  as  have  been  described 
secondary  distortions  of  the  limb  are  often  present.  Knock-knee 
rarely  requires  other  treatment  than  daily  manual  correction  in 
connection  with  the  massage  of  the  foot  and  leg.  Hyperextension 
at  the  knee  will  correct  itself  during  the  treatment  of  the  foot,  which, 


SUPPLEMENTAL  OPERATIONS  797 

being  fixed  in  an  attitude  of  dorsal  flexion,  obliges  the  patient  to 
bend  the  knee  habitually  in  walking.  Inward  rotation  of  the  leg 
upon  the  thigh  is  often  present.  This  may  be  overcome  by  methodi- 
cal manipulation  and  bv  the  use  of  a  brace  attached  to  a  pelvic 
band  (Fig.  627). 

In  many  instances,  particularly  in  childhood  and  adolescence,  the 
patient  has  so  long  walked  with  exaggerated  outward  rotation  of 
the  femur  that  after  correction  of  the  deformity  no  inward  rotation 
of  the  foot  appears,  even  though  inward  rotation  of  the  tibia  be 
presents  In  other  cases  the  inward  rotation  of  the  foot  is  caused 
by  a  failure  to  completely  replace  the  astragalus  between  the  mal- 
leoli. Occasionally  the  tibia  is  actually  twisted  on  its  long  axis,  so 
that  an  osteotomy  may  be  required  in  order  to  overcome  the 
deformity. 

It  might  seem  on  first  consideration  that  if  immediate  correction 
of  deformity  can  be  accomplished  so  easily  in  the  confirmed  cases  it 
should  be  employed  even  in  infancy.  There  are,  however,  practical 
reasons  against  it:  First,  because  the  foot  is  so  small  that  it  cannot 
be  easily  manipulated;  second,  because  even  after  it  is  corrected  it 
must  be  supported  until  the  child  begins  to  walk;  and  third,  because 
the  foot  can  be  so  readily  straightened  without  operation,  which, 
even  of  so  slight  a  character,  is  sometimes  the  cause  of  much  anxiety 
to  the  parents.  For  these  reasons,  although  immediate  reduction 
of  deformity  is  a  practicable  operation,  it  is  usually  postponed  until 
a  later  time. 

Subcutaneous  Tenotomy. — The  division  of  tendons  and  other 
tissues  by  the  subcutaneous  method  has  been  mentioned  inci- 
dentally, but  as  it  has  so  long  occupied  an  important  and  even  at 
one  time  the  most  important  place  in  the  treatment  of  club-foot, 
the  operation  and  its  effects  may  be  described  somewhat  in  detail. 

Tenotomy,  as  has  been  stated,  is  performed  for  the  purpose  of 
removing  an  obstacle  to  the  overcorrection  of  deformity.  In  the 
acquired  or  paralytic  form  of  talipes  one  or  more  shortened  tendons 
may  be  the  chief  obstacles,  but  in  the  congenital  form,  in  which  all 
the  tissues  have  grown  into  deformity,  the  shortened  tendons  are  by 
no  means  the  only  resistant  parts,  and  tenotomy  should  be  con- 
sidered, therefore,  merely  as  an  incident  in  correction.  In  the  ordi- 
nary treatment  of  infantile  club-foot  tenotomy  is  usually  unneces- 
sary and  in  the  great  majority  of  cases  division  of  the  tendo-Achillis 
is  alone  required. 

When  the  tendon  has  been  divided  the  deformity  is  immediately 
overcorrected ;  thus  the  two  extremities  are  separated  to  the  extent 
necessary  for  the  improved  position.  At  the  end  of  three  weeks  or 
more,  or  at  the  time  when  the  first  plaster  bandage  is  removed,  the 
space  will  be  filled  with  new  material,  and  in  another  month  the 
splice,  which  will  be  somewhat  larger  and  thicker  than  the  normal, 
should  be  strong  enough  for  use.     The  slight  thickening  at  the  site 


798  DEFORMITIES  OF   THE  FOOT 

of  the  operation  may  persist  a  year  or  more,  but  practically  the  new 
and  lengthened  tendon  is  perfectly  normal,  as  is  the  function  of  the 
muscle  of  which  it  is  a  part. 

The  process  of  repair  is  somewhat  as  follows:  Immediately  after 
the  operation  the  space  between  the  divided  ends  of  the  tendon  is 
filled  or  partially  filled  with  blood;  then  leukocytes  appear,  which, 
with  those  in  the  blood  clot,  serve  as  a  support  for  the  plasma  cells 
which  migrate  from  between  the  fasciculi  of  the  tendon  and  from  the 
tendon  sheath.  The  fibrin  and  red  corpuscles  of  the  clot  are 
absorbed;  the  extremities  of  the  divided  tendon  soften  and  become 
fused  with  the  new  material,  which  begins  to  take  on  the  form  and 
consistency  of  true  tendon  and  to  separate  itself  from  the  adherent 
sheath.  This  new  tendon  differs  from  the  normal  structure  in  that 
the  fibrous  fasciculi  are  more  irregular  and  its  substance  is  more  like 
scar  tissue,  but  practically  it  is  normal  in  its  appearance  and 
function.^ 

Since  the  tendon  sheath  serves  an  important  purpose  in  repair, 
it  should  be  disturbed  as  little  as  possible.  For  this,  as  well  as  for 
other  obvious  reasons,  subcutaneous  tenotomy  of  the  tendo-i^chillis, 
which  is  so  prominent  and  so  distinct  from  other  important  parts, 
is  to  be  preferred;  but  if  more  extensive  division  of  other  tendons 
is  required  the  open  operation  is  often  indicated. 

Division  of  the  Tendo-Achillis. — For  this  operation  anesthesia  is 
usually  required,  and  it  is  hardly  necessary  to  state  that  surgical 
cleanliness,  even  in  so  slight  a  procedure,  is  essential. 

The  instrument  should  be  small  and  very  sharp,  so  that  no  force 
is  required  in  the  operation;  the  blade  should  be  as  long  as  the  ten- 
don is  wide.  The  patient  is  turned  upon  the  side  or  to  the  prone 
position,  so  that  the  foot  may  be  held  with  the  heel  upward  by  the 
left  hand.  The  position  and  size  of  the  tendon  is  ascertained  by 
careful  palpation,  and  the  knife  is  then  inserted  to  its  inner  side,  at 
about  the  level  of  the  extremity  of  the  internal  malleolus.  The  flat 
surface  of  the  blade  is  held  parallel  to  the  tendon,  and  it  is  passed 
beneath  it  until  its  point  can  be  felt  beneath  the  skin  on  the  opposite 
side.  The  edge  is  then  turned  upward  and  the  tendon,  being  made 
tense,  is  divided  by  a  sawing  motion  of  the  knife.  When  the  division 
is  complete,  as  indicated  by  the  separation  of  the  divided  ends,  the 
knife  is  withdrawn,  and  the  minute  opening  in  the  skin,  from  which 
there  is  usually  slight  bleeding,  is  covered  with  a  pledget  of  aseptic 
cotton.  The  foot  is  forced  into  dorsal  flexion  and  is  securely  fixed 
by  a  plaster  bandage.  In  applying  the  dressing  one  should  take  care 
that  no  pressure  is  brought  upon  the  seat  of  operation,  as  this  might 
interfere  with  the  eftusion  of  plastic  material.  As  soon  as  the  dis- 
comfort attending  the  operation  has  subsided  the  patient  is  encour- 
aged to  stand  and  to  walk.     Functional  use  stimulates  the  circula- 

1  R.  Seggel:  Beitr.  z.  kliu.  Chir.,  1903,  xxxvii,  342. 


SUPPLEMENTAL  OPERATIONS  799 

tion,  and,  far  from  retarding  repair,  it  is  in  my  experience  an  impor- 
tant agent  in  assuring  firm  and  rapid  union. 

The  Open  Method. — ^The  tendon  may  be  exposed  by  a  long  vertical 
incision;  it  is  then  split  for  a  distance  of  two  or  three  inches,  and  the 
division  is  completed  at  the  upper  and  lower  ends.  The  two  halves 
are  then  allowed  to  slide  by  one  another  until  the  necessary  elonga- 
tion has  been  obtained  and  are  then  sutured. 

Theoretically,  this  operation,  which  assures  union  at  a  point  of 
selection,  is  safer  than  the  subcutaneous  method,  in  which  the  ends 
of  the  tendon  are  separated  from  one  another;  practically,  it  is  in 
this  class  of  cases  less  satisfactory  in  its  results  than  the  subcutaneous 
method. 

Division  of  the  plantar  fascia  is  often  necessary.  The  tenotome 
is  inserted  beneath  the  skin  at  about  the  centre  of  the  concavity  to 
one  or  the  other  side  of  the  central  band  of  the  fascia,  which  is 
divided  by  a  sawing  motion  of  the  knife.  The  part  is  put  upon  the 
stretch,  and  other  resisting  bands  to  the  outer  and  inner  side  are 
divided  in  the  same  manner;  the  cavus  is  then  corrected  by  manual 
or  instrumental  force. 

Division  of  the  tibialis  anticus  is  not  often  necessary,  as  this  ten- 
don offers  little  resistance  to  the  rectification  of  deformity  of  the 
ordinary  type. 

The  tendon  of  the  tibialis  posticus  may  be  divided  together  with 
that  of  the  tibialis  anticus  near  the  points  of  attachment.  If  the 
operation  is  required  it  may  be  combined  with  simultaneous  section 
of  the  calcaneonavicular  ligament,  with  which  are  blended  the  anterior 
part  of  the  deltoid  and  fibres  of  the  anterior  ligament  of  the  ankle. 
The  foot  should  be  strongly  abducted  to  make  the  parts  tense.  The 
tenotome  is  inserted  directly  in  front  of  the  anterior  border  of  the 
internal  malleolus,  its  cutting  edge  being  turned  forward  between 
the  skin  and  the  ligament.  It  is  then  turned  toward  the  ligament, 
and  the  tissues  are  divided  to  the  bone.  The  blade  is  then  made  to 
enter  the  interval  between  the  astragalus  and  the  scaphoid,  and  is 
carried  downward  and  forward  to  divide  the  inferior  part  of  the 
ligament  and  at  the  same  time  the  tendons  of  the  tibialis  anticus 
and  posticus. 

The  posterior  ligament  of  the  ankle-joint  may  be  divided  or  suf- 
ficiently weakened  so  that  it  may  be  ruptured  after  section  of  the 
tendo-Achillis  by  passing  the  knife  directly  downward  in  the  middle 
line  upon  the  upper  border  of  the  astragalus.  As  has  been  stated 
in  resistant  cases  the  open  operation  is  to  be  preferred. 

The  Correction  of  Confirmed  Club-foot  by  the  Method  of  Julius  Wolff. — 
Wolff's  treatment  of  club-foot,  as  described  by  Freiberg,  a  former 
assistant  in  his  clinic,  may  be  summarized  as  follows '}  The  patient 
is  anesthetized,  and  with  the  hands  and  by  the  use  of  a  moderate 

'  Med.  News,  October  29,  1892. 


800 


DEFORMITIES  OF   THE  FOOT 


amount  of  force  the  deformity  is  reduced  as  far  as  possible.  The 
foot  is  held  in  the  improved  position  by  means  of  strips  of  adhesive 
plaster  passing  from  the  dorsal  surface  of  the  inner  border  of  the 
foot  under  the  sole  and  up  to  the  outer  aspect  of  the  leg.  The  leg 
and  foot  are  then  covered  with  cotton  from  the  tuberosity  of  the 
tibia  to  the  tips  of  the  toes,  and  a  plaster  bandage  is  applied.  As  the 
plaster  is  hardening  the  position  of  the  foot  is  still  further  improved 
by  pressing  the  heel  inward  and  the  forefoot  outward  and  upward. 
Two  fenestra  are  cut  in  the  plaster  at  the  points  of  greatest  pressure 
—one  over  the  external  surface  of  the  ankle  and  the  other  over  the 
internal  surface  of  the  great  toe.  If  tenotomy  is  considered  neces- 
sary it  is  usually  performed  as  a  preliminary 
operation  several  days  before  forcible  cor- 
rection. 

On  the  third  or  fourth  day  after  the  oper- 
ation a  wedge-shaped  section  is  cut  from  the 
bandage  on  the  outer  side  of  the  ankle-joint 
and  a  linear  division  is  made  about  the  ankle, 
so  that  the  leg  and  the  foot  parts  of  the  ban- 
dage are  separated  (Fig.  628) .  The  leg  being 
held  firmly,  the  foot  is  forced  outward  and 
upward  to  the  extent  that  the  wedge-shaped 
opening  on  the  plaster  will  allow,  and  the 
two  sections  are  then  united  by  a  covering 
of  plaster  bandage.  For  the  secondary  cor- 
rection anesthesia  is  not  required.  At  in- 
tervals of  several  days  larger  wedges  are 
removed,  and  the  manipulation  is  repeated 
until  the  patient  stands  with  the  foot  in  a 
satisfactory  attitude;  that  is,  in  pronation, 
abduction,  and  dorsifiexion.  If  the  deform- 
ity is  extreme  the  bandage  may  be  reapplied 
before  the  correction  is  completed  with  ad- 
vantage. One  should  take  care  that  the  toes  are  not  compressed, 
but  lie  on  the  same  plane  in  normal  relation  to  one  another. 

When  rectification  is  complete  the  plaster  bandage  is  covered 
with  strips  of  pine  shavings,  held  in  place  by  a  crinoline  bandage, 
and  painted  with  carpenter's  glue.  When  this  is  hardened  the  whole 
is  covered  with  a  thin  silicate  bandage;  over  this  the  shoe  is  fitted 
and  the  patient  is  encouraged  to  walk.  This  form  of  dressing  is 
used  until  the  transformation  of  the  deformed  parts  may  be  supposed 
to  be  complete,  the  time  varying  with  the  case,  from  a  few  months 
to  a  year.  The  time  required  for  the  primary  correction  is  from  a 
week  to  a  month.  ^Vhen  the  bandage  is  finally  removed  massage 
and  exercise  are  to  be  employed.^    Wolff's  treatment  is  an  efficient, 

1  Julius  Wolff:  Ueber  die  Ursachen,  das  Wesen  und  die  Behandlung  des  Klump- 
fusses,  Berlin,  1905. 


Fig.  628.— The  points 
at  which  the  bandage  is 
divided  and  the  wedge 
removed.      (Freiberg.) 


SUPPLEMENTAL  OPERATIONS 


801 


though  tedious,  means  of  correction  that  may  be  employed  when 
operative  facilities  are  not  at  command. 

Forcible  Correction  of  Deformity  by  Means  of  Osteoclasts  and 
Wrenches. — In  place  of  manual  correction  greater  force  may  be 
employed  by  means  of  wrenches  or  osteoclasts  to  overcome  the 
deformity.  There  is  this  important  difference  between  the  two 
procedures :  force  may  be  applied  by  the  hands  for  as  long  a  time  as 
is  necessary  without  fear  of  injury,  while  force  applied  by  a  machine 
must  be  momentary  because  of  the  pressure  and  strain  on  the  parts 


Fig.  629.  —  The  Thomas 
wrench  as  used  in  the  correction 
of  club-foot. 


Fig.'  630.- 


-Resistant   club-foot   in    later   child- 
hood.    (See  Fig.  632.) 


where  the  leverage  is  exerted.  Manual  force  continuously  applied 
may  be  supposed  to  stretch  the  resistant  parts,  and  although  much 
less  power  is  exerted  it  is  really  more  effective  than  the  sudden  and 
momentary  force  of  the  wrench  or  osteoclast,  because  it  may  be 
continued  until  the  deformity  has  been  overcorrected,  while  com- 
plete correction  by  means  of  instruments  may  necessitate  several 
operations. 

The    Thomas    Method. — Of   instrumental  correction  that  by 
means  of  the  Thomas  wrench  is  one  of  the  simplest  and  most 
51 


802  DEFORMITIES  OF   THE  FOOT 

eflficient.  The  wTenching  may  or  may  not  be  preceded  by  tenotomy, 
a  point  to  be  decided  by  the  resistance  of  the  parts.  As  a  rule 
division  of  the  tendo-Achilhs  alone  is  necessary.  The  instrument 
is  a  simple  heavy  "monkey-^vrench,"  of  which  the  jaws  have  been 
replaced  by  two  strong  pins  slightly  bulbous  at  the  ends  to  keep  the 
covers  of  rubber  tubmg  from  slipping  off. 

The  "UTench  is  applied  to  the  inner  side  of  the  foot  and  screwed 
down  so  that  it  may  "bite"  and  hold  its  place  firmly,  for  if  it  slips  it 
is  likely  to  abrade  or  tear  the  skin;  then  with  considerable  force  the 
foot  is  twisted  outward  and  upward  (Fig.  629).  The  "keynote"  of 
of  the  operation  is  to  so  wrench  the  foot  that  it  loses  its  elasticity 
and  shows  no  tendency  to  recoil  toward  deformity.  The  foot  is 
then  placed  in  the  best  possible  position,  and  is  retained  there  by  the 
Thomas  foot  splint  or  by  a  plaster  splint.  In  certain  instances 
one  may  complete  the  rectification  at  one  operation,  but  this  is  not 
usually  attempted,  the  procedure  being  repeated  at  intervals  of  a 
few  days  unti  the  deformity  has  been  overcorrected.  In  very 
resistant  cases  eight  to  ten  applications  of  force  may  be  necessary. 
^^Tlen  the  deformity  has  been  rectified  the  foot  is  held  in  the  over- 
corrected  position  for  several  weeks  by  the  splint  or  by  the  plaster 
bandage. 

As  a  walking  appliance  a  simple  upright  of  iron  with  a  calf  band 
is  applied  to  the  imier  side  of  the  leg,  from  a  point  just  below  the 
knee  to  the  heel  of  the  shoe  into  which  it  is  inserted,  as  is  the 
Thomas  knock-knee  brace  (Fig.  460).  By  bending  the  upright  the 
foot  may  be  held  in  slight  valgus,  and  this  position  is  still  further 
assured  by  making  the  outer  side  of  the  sole  of  the  shoe  thicker  than 
the  inner,  so  that  the  weight  falls  upon  the  inner  border  of  the  foot. 
In  many  instances  the  walking  brace  may  be  dispensed  with  in 
the  after-treatment,  but  a  light  brace  is  usually  worn  to  hold  the 
foot  in  the  corrected  position  during  the  night,  until  the  power  of 
the  abductors  and  dorsal  flexors  has  been  regained.  Massage  and 
manipulation  are  used  in  the  after-treatment  in  the  manner  already 
described. 

When  properly  applied  the  treatment  is  satisfactory  and  free 
from  danger.  Sloughing  of  the  tissues  caused  by  the  pressure  of  the 
instrument  has  been  reported,  but  such  accidents  have  not  occurred 
in  the  extensive  practice  of  Thomas  and  Jones. 

CoRRECTiox  BY  Mk^xs  OF  THE  OSTEOCLAST. — The  late  Mr. 
Grattan,  of  Cork,  used  the  osteoclast  that  goes  by  his  name  (Fig. 
464)  to  crush  and  to  overcorrect  resistant  club-foot.  The  operation 
may  include  besides  the  correction  of  the  deformity  of  the  foot 
itself,  fracture  of  the  leg  above  the  malleolus,  to  turn  the  foot  toward 
valgus,  and  a  second  fracture  half-way  up  the  leg,  to  overcome  the 
inward  rotation  or  twist  of  the  tibia.  ]Mr.  Grattan's  results  were 
very  satisfactory.  Other  appliances  constructed  on  somewhat 
similar  principles  may  be  employed. 


SUPPLEMENTAL  OPERATIONS 


803 


Of  these  the  Lorenz  osteoclast^  and  the  Bradford"  lever  apparatus 
are  the  most  effective. 

The  Open  Incision  Combined  with  Forcible  Rectification  of  Deformity. 
— Phelps'  Operation. — In  very  resistant  cases  the  open  incision  is  to 
be  preferred  to  the  use  of  force  supplemented  by  subcutaneous 
tenotomy  because  of  the  opportunity  thus  offered  for  the  recogni- 
tion and  for  intelligent  selection  of  structures  that  require  division 
in  the  final  correction  of  the  deformity. 

Phelps'  operation  is  essentially  the  division  of  resistant  parts 
through  an  incision  on  the  inner  border  of  the  foot,  combined 
with  sufficient  force,  manual  or  instrumental,  to  overcorrect  the 
deformity.  It  is  the  most  conservative  of  the  more  radical  pro- 
cedures, and  by  this  means  even  the  most  severe  type  of  deformity 


Fig.  631. — Illustrating  the  correction  of  the  left  foot  by  Phelps'  operation. 

in  the  adult  can  be  corrected;  that  is  to  say,  the  external  deformity 
may  be  overcome  and  a  serviceable  foot  may  be  assured  to  the 
patient. 

The  steps  of  the  Phelps  operation  are  as  follows:  After  proper 
surgical  preparation  the  Esmarch  bandage  is  applied.  The  tendo- 
Achillis  and  usually  the  posterior  ligaments  of  the  ankle  are  divided 
subcutaneously,  and  by  manual  or  instrumental  force  one  attempts 
to  correct  the  plantar  flexion.  An  incision  is  then  made  on  the 
inner  border  of  the  foot,  just  below  and  in  front  of  the  internal 
malleolus,  which  is  extended  directly  downward  over  the  head  of 
the  astragalus  to  include  the  inner  quarter  of  the  sole.     Through 

1  Wien.  Klinik,  November  and  December,  1895. 
-  Bradford  and  Lovett:  2d  ed.,  p.  414. 


804 


DEFORMITIES  OF   THE  FOOT 


the  incision  all  resistant  parts  are  divided  in  order,  as  stated  bv 
Phelps. 

1.  The  tibialis  posticus,  and  the  anticus  if  it  offers  resistance. 

2.  The  abductor  hallucis. 

3.  The  plantar  fascia. 

4.  The  flexor  brevis  digitorum. 

5.  The  long  flexor  of  the  toes. 

6.  The  deltoid  ligament  in  all  its  branches. 

During  the  successive  division  of  the  tissues  repeated  attempts 
are  made  to  correct  the  foot,  and  only  those  structures  are  divided 
that  present  themselves  as  tense  and  resistant  tissues  when  the  foot 
is  forciblv  abducted. 


Fig.  632.— The  left  foot  (Fig.  630)  corrected  by  Phelps" 
osteotomv  of  the  os  calcis. 


operation  and  by  cuneiform 


In  the  adult  type  of  club-foot  no  particular  eft'ort  is  made  to  recog- 
nize the  different  structures,  but  all  the  tissues  on  the  inner  side  of 
the  foot,  including  bloodvessels  and  ner\'es,  the  deep  ligaments,  and 
occasionally  the  tendon  of  the  peroneus  longus  muscle,  are  di\dded. 
Even  then  it  is  necessary  to  apply  considerable  force  to  correct  the 
deformity.  In  certain  instances  the  rectification  of  deformity 
necessitates  osteotomy  of  the  neck  of  the  astragalus  or  the  removal 
of  a  cuneiform  section  from  the  os  calcis.  The  object  of  the  Phelps 
operation  is,  by  division  of  resistant  tissues  and  by  the  use  of  force, 
to  overcorrect  the  deformed  foot  at  one  sitting,  and  as  much  force 


SUPPLEMENTAL  OPERATIONS 


805 


and  as  extensive  division  of  tissues  as  are  required  to  accomplish 
this  object  should  be  employed  by  the  operator. 

When  the  foot  can  be  held  in  the  desired  position  without  resist- 
ance the  wound  is  covered  w^ith  Lister  protective,  the  foot  and  leg 
are  thickly  covered  with  gauze  and  cotton,  a  plaster  bandage  is 


Fig.  633.- 


-The  relation  of  the   leg   and   foot   after   astragalectomy  and  backward 
displacement. 


applied,  and  the  limb  is  elevated.  The  large,  gaping  wound  closes 
by  granulation  in  from  one  to  three  months.  The  first  bandage 
is  usually  changed  at  the  end  of  one  or  two  weeks,  and  the  patient 
then  begins  to  bear  weight  on  the  foot. 

By  this  operation  the  foot,  even  in  severe  cases  in  adult  life,  may 
be  made  straight  in  appearance.     It  is  evident,  however,  that  in 


806  DEFORMITIES  OF   THE  FOOT 

such  cases  the  correction  of  the  deformity  of  the  bones  is  by  no  means 
perfect,  for  the  forefoot  may  be  simply  twisted  outward  and  upward, 
while  the  astragalus  and  os  calcis  may  remain  in  an  approximation 
to  their  original  deformity.  The  operation  is  most  satisfactory  in 
those  cases  of  resistant  varus  in  which  the  equimis  deformity  has  been 
overcome.  After  thorough  overcorrection  by  the  Phelps  operation 
the  danger  of  recurrence  of  deformity  in  the  adult  and  adolescent 
type  of  club-foot  is  not  great,  and  in  many  instances  support  other 
than  that  of  the  plaster  bandage  for  several  months  after  the  opera- 
tion may  be  unnecessary;  but  in  childhood  the  ordinary  precautions 
in  after-treatment  to  prevent  relapse  will  be  necessary. 

Operations  on  the  Bones. — Osteotomy  of  the  neck  of  the  astrag- 
alus, as  a  supplementary  part  of  the  operation  of  forcible  correction, 
has  been  mentioned.  In  certain  instances,  particularly  in  the 
adolescent  or  adult  tj^e  of  deformity,  the  displaced  astrogalus  may 
offer  such  an  obstacle  to  correction  that  its  removal  is  indicated. 

Astragalectomy. — ^The  astragalus,  which  in  club-foot  is  displaced 
forward,  may  be  removed  easily  by  means  of  an  incision  passing 
over  its  most  prominent  part,  in  a  direction  forward  and  downward 
from  the  tip  of  the  external  malleolus,  between  the  tendons  of  the 
peroneus  brevis  and  tertius.  The  soft  parts  are  drawn  aside,  the 
ankle  and  astragalonavicular  joint  are  opened,  and  the  attachments 
to  the  navicular,  and,  as  far  as  possible,  those  at  the  inner  and  outer 
border,  are  divided.  The  foot  is  then  adducted  so  that  the  head  of 
the  bone  may  be  seized  with  forceps  and  draw^n  upward,  the  inter- 
osseous ligament  and  the  internal  lateral  ligament  having  been 
divided  with  curved  scissors,  it  is  removed.  If  after  removal  of  the 
astragalus  the  varus  persists,  it  should  be  supplemented  by  cunei- 
form osteotomy  of  the  os  calcis.  The  foot  is  then  displaced  backward 
to  restore  the  prominence  of  the  heel.  A  useful  movable  foot  may 
be  obtained  by  this  operation,  but  it  by  no  means  assures  the 
patient  from  recurrence  of  deformity.  Astragalectomy  is  never 
indicated  as  a  primary  operation,  in  childhood  at  least.  The  varus 
should  be  thoroughly  corrected  as  a  preliminary  procedure,  for  until 
then  the  resistance  that  the  astragalus  offers  to  dorsal  flexion 
cannot  be  accurately  estimated  (Fig.  635). 

Cuneiform  Osteotomy. — The  removal  of  cuneiform  sections  of 
bone  from  the  outer  border  of  the  foot  is  sometimes  indicated  when 
the  deformity  is  of  long  standing,  but  the  operation  should  be 
secondary  to  other  methods  of  correction.  The  aim  should  be  to 
lengthen  the  contracted  and  shortened  tissues  on  the  inner  border 
of  the  foot  to  the  extent  required  for  reposition,  not  to  remove  bone 
to  accommodate  these  shortened  tissues.  If  this  has  been  shown 
to  be  impossible  by  ordinary  means,  then  removal  of  bone  may  be 
indicated;  but  it  is  not  often  necessary  in  childhood  or  even  in 
adolescence.  If  sufficient  bone  is  cut  away  from  the  adult  foot  to 
permit  complete  correction  of  the  deformity,  relapse  is  not  usual; 


SUPPLEMENTAL  OPERATIONS 


807 


Fig.  634. — Resistant  club-foot  in  later  childhood.      (See  Fig.  635.) 


Fig.  635. — After  forcible  correction  and         Fig.  636. — Partially  corrected  club-foot, 
astragalectomy.     (See  Fig.  634.)  showing  secondary  knock-knee. 


808  DEFORMITIES  OF   THE  FOOT 

but  in  childhood,  as  has  been  stated,  no  operation  A\ill  take  the  place 
of  after-treatment. 

The  treatment  by  cuneiform  osteotomy  as  it  is  ordinarily  carried 
out  is  sufficiently  simple.  A  wedge-shaped  section  of  bone  of  suffi- 
cient size  to  permit  correction  of  deformity  is  taken  from  the 
astragalus,  the  os  calcis,  cuboid,  and,  if  necessary,  it  may  include 
the  navicidar  also.  The  external  malleolus  may  be  removed  if  it 
interferes  with  reposition.  Preliminary  fasciotomies  and  tenotomies 
are  usually  performed,  but  those  who  favor  this  method  of  treat- 
ment rarely  use  force  in  reposition.  The  foot  is  retained  in  proper 
position  until  the  wounds  are  closed;  then  plaster  bandages  are 
employed  for  several  months.  Braces  are  seldom  used  in  the  after- 
treatment. 


Fig.  637. — Showing  the  effect  of  the  ordinary  cuneiform  osteotomj-,  the  wedge 
having  been  taken  from  the  body  of  the  astragalus  and  the  anterior  part  of  the  os 
calcis.     The  astragalus  is  displaced  forwai'd  in  its  relation  to  the  malleoli. 

Secondary  Osteotomy. — In  certain  cases  of  relapsed  or  ineffectively 
treated  club-foot,  even  in  childhood,  deformity  of  the  os  calcis 
interferes  with  correction  of  the  foot.  In  such  instances  the  removal 
of  a  cimeiform  section  of  bone  from  the  anterior  extremity  may  be 
of  service.  'Osteotomy  of  the  tibia  may  be  required  in  cases  of  per- 
sistent inward  rotation. 

Simple  Mechanical  Rectification  of  Deformity  in  Walking 
Children  and  in  Later  Years. — It  has  been  stated  that  simple 
mechanical  rectification  of  deformity  was  possible  even  in  adoles- 
cence, but  that  the  time  required  for  such  treatment,  usually  extend- 
ing over  several  years,  as  a  rule,  excluded  it  from  consideration. 

The  simplest  mechanical  treatment  is  that  by  which  the  foot  is 


SUPPLEMENTAL  OPERATIONS 


809 


slowly  forced  from  equinovarus  into  equinovalgus  by  a  brace  on  the 
lever  principle,  which  is  at  first  shaped  to  the  deformity,  and  is  then 
gradually  straightened  as  the  resistance  diminishes.  When  the 
midpoint  has  been  passed  between  varus  and  valgus  the  weight  of 
the  body  aids  in  the  correction  of  the  remaining  varus  and  equinus. 
The  modification  of  the  Taylor  brace  used  by  Judson,  an  advocate 
of  pure  mechanics  in  the  treatment  of  club-foot  will  serve  to  illus- 
trate the  type  of  apparatus  which,  with  slight  change,  may  be 
employed  to  correct  or  to  support  the  weakened  or  deformed  foot. 


Fig.  638  Fig.  639 

Figs.  638  and  639. — The  Judson  brace.  Fig.  638  shows  the  construction  of  the 
brace;  the  foot-plate,  with  internal  flange  or  "riser,"  the  upright  riveted  to  it,  and  the 
calf  band.    Fig.  639  shows  the  brace  adjusted  to  fit  the  deformed  foot. 


The  brace  consists  of  an  upright,  a  flat,  tapering  bar  of  mild  steel, 
a  foot  plate  of  steel  from  18  to  16  gauge,  and  a  strong  calf  band. 
The  shape  of  the  brace,  the  method  of  its  attachment  to  the  leg  by 
straps  of  webbing,  and  its  effect  in  gradually  changing  the  attitude 
of  the  foot  from  varus  to  valgus  are  shown  in  the  accompanying 
figures. 

The  upright  is  firmly  riveted  to  the  foot  plate  in  the  angle  of 
deformity,  so  that  the  patient  must  walk  upon  his  toes;  as  the 
equinus  is  decreased  by  the  influence  of  the  weight  of  the  body  this 
angle  is  lessened  (Figs.  640  and  644). 

The  important  points  are  that  the  brace  shall  be  strong  enough 
to  hold  its  place  under  the  strain  of  use  and  that  the  foot  shall  be 
firmly  secured  to  it,  whether  one  or  many  straps  of  w^ebbing  are 


810 


DEFORMITIES  OF   THE  FOOT 


required,  as  may  be  seen  in  the  figures.  The  use  of  massage  and 
manipulation  is,  of  course,  combined  with  the  mechanical  treatment. 

By  persistant  attention  to  the  details  of  treatment  satisfactory 
residts  can  be  obtained  occasionally  by  this  method  in  the  less 
resistant  cases,  even  in  adolescence. 

Review  of  the  Principles  of  Treatment  of  Congenital  Talipes 
Equinovanis. — The  object  of  treatment  is  to  overcome  and  to 
overcorrect  the  deformity  at  as  early  a  period  of  life  as  is  possible, 
and  as  quickly  as  possible.     The  object  of  overcorrection  is  to  over- 


FiG.  640  Fig.  641  Fig.  642 

Figs.  640,  641  and  642. — Showing  the  progressive  reduction  of  deformity.  Fig. 
640  shows  the  ordinarj-  attitude  of  the  neglected  club-foot  in  childhood  with  the 
adjustment  of  the  brace,  it  being  bent  to  accommodate  the  deformity.  Fig.  641 
shows  additional  details — an  upright  spur,  useful  in  holding  the  heel  and  for  the 
attachment  of  straps;  the  spur  of  sheet  brass  that  may  be  bent  over  the  great  toe  to 
hold  it  in  position.  Fig.  642  shows  other  details  in  the  method  of  attachment,  a  strip 
of  adhesive  plaster,  Tsith  two  tails  in  the  place  of  the  band  of  webbiag.  This  aids 
in  fixing  the  heel.     (See  Figs.  643  and  644.) 

come  all  the  resistance  of  the  tissues  that  may  even  in  the  slightest 
degree  limit  the  normal  range  of  motion  in  any  direction.  The  foot 
must  be  fixed  in  the  overcorrected  position  until  the  tendency 
toward  deformity  is  overcome. 

It  must  be  supported  in  the  proper  relation  to  the  leg,  and  at  a 
right  angle  with  it,  until  the  muscular  balance  has  been  reestablished 
by  stunidation  of  the  weaker  and  by  limitation  of  the  activity  of  the 
stronger  muscles,  and  until  transformation  of  the  internal  structure 
has  been  completed. 


SUPPLEMENTAL  OPERATIONS 


811 


If  efficient  mechanical  treatment  is  applied  at  the  proper  time — 
that  is  to  say,  in  earliest  infancy — no  operation  other  than  division 
of  the  tendo-Achillis  or  posterior  Hgaments  should  be  required. 

If  the  deformity  is  not  corrected  or  is  but  partially  corrected 
when  the  child  begins  to  walk,  some  form  of  operation  is,  as  a  rule, 
indicated;  but  division  of  the  resistant  tissues  must  always  be  com- 
bined with  the  employment  of  sufficient  force  to  accomplish  the 
desired  result,  viz.,  overcorrection  of  the  deformity.  Forcible 
manual  correction,  applied  in  the  manner  described,  is  the  most 


Fig.  643  Fig.  644 

Figs.  643  and  644. — Showing  the  progressive  reduction  of  deformity  and  illus- 
trating the  process  of  changing  the  shape  of  the  brace  from  time  to  time  until  it  holds 
the  foot  in  valgus.     (See  Fig.  640.) 


efficient  means  of  attaining  this  object.  No  instrument  can  equal 
the  hand.  The  force  that  can  be  applied  by  the  hand  is  sufficient 
for  the  correction  of  all  the  ordinary  cases  in  early  childhood,  and, 
in  combination  with  subcutaneous  or  open  division  of  the  more 
resistant  tendons  and  ligaments,  even  in  later  childhood  and 
adolescence. 

Forcible  correction  by  the  Thomas  wrench  under  the  same  condi- 
tions is  an  efficient  treatment,  and  the  instrument  may  be  used  to 
supplement  manual  correction  in  resistance  cases,  but  there  is  a 
manifest  disadvantage  in  submitting  a  patient  to  a  succession  of 


812  DEFORMITIES  OF   THE  FOOT 

wrencliings  as  was  the  Thomas  practice,  if  immediate  o\'ercorrection 
can  be  attained  at  one  operation. 

The  Phelps  operation,  which  combines  thorough  division  of  the 
resistant  parts  with  the  appHcation  of  sufficient  force  to  overcorrect 
the  foot,  is  of  value  in  the  more  resistant  cases  of  varus  in  adolescence 
in  adult  life,  and  in  extremely  resistant  cases  in  childhood. 

Astragalectomy  and  cuneiform  osteotomy  are  never  indicated  as 
primary  operations,  but  one  or  the  other  or  both  may  be  necessary 
for  the  complete  rectification  of  the  deformity  when  other  means 
have  failed. 

Complete  cure  of  deformity,  even  in  the  later  years  of  childhood, 
is  possible  by  means  of  braces  alone,  but  such  treatment  is  very 
tedious.  It  requires  the  continuous  supervision  of  the  skilled 
orthopedist,  as  well  as  the  intelligent  and  persistent  cooperation 
of  the  parents.  The  results  are  in  no  way  superior  to  those  attained 
by  more  rapid  methods,  while  the  disadvantages  of  long-continued 
use  of  braces  are  sufficiently  obvious.  To  the  popular  faith  in 
braces  as  a  cure-all  of  deformity,  and  to  the  unintelligent  use  of 
braces,  may  be  ascribed  now,  as  in  former  times,  the  greater  number 
of  failures  in  treatment  of  this  eminently  curable  deformity.  On  the 
other  hand,  the  belief,  so  prevalent  among  physicians,  that  a  radical 
operation,  if  it  does  not  absolutely  assure  a  cure,  is,  at  least,  the 
essential  part  of  the  treatment  is  equally  fallacious. 

Rectification  of  deformity,  by  whatever  means,  simply  completes 
the  first  stage  of  treatment.  Perfect  cure  can  be  assured  only  by 
attention  to  the  small  details  of  after-treatment,  by  checking  the 
slightest  impulse  toward  deformity,  and  by  guiding  the  unbalanced 
foot  toward  normal  functional  use. 

OTHER  VARIETIES  OF  CONGENITAL  TAUPES. 

Forms  of  congenital  distortion  of  the  foot  other  than  equino varus 
are  not  uncommon;  but,  as  a  rule,  these  deformities  are  so  slight, 
and,  as  compared  to  equino  varus,  so  easily  remedied  that  they  are 
relatively  of  little  importance. 

Congenital  Talipes  Varus. — Eighty-nine  cases  of  simple  varus 
are  recorded  in  the  table  of  statistics  in  a  total  of  2103  congenital 
deformities  of  the  foot. 

This  deformity  often  appears  to  be  an  incomplete  form  of  equino- 
varus,  but  in  some  instances  there  is  simply  an  inward  twist  of  the 
forefoot  without  inversion  (Fig.  574).  In  some  cases  of  this  char- 
acter, the  forefoot  is  apparently  drawn  inward  by  the  active  move- 
ment of  the  great  toe,  which,  in  such  cases,  seems  almost  prehensible. 
(See  Pigeon-toe.)  In  the  more  marked  form  the  foot  is  adducted 
and  inverted,  and  the  tissues  are  very  resistant. 

The  slight  grades  of  deformity  may  be  treated  by  simple  man- 
ipulation, and  if  distortion  persists  after  the  first  year  the  shoe 


OTHER   VARIETIES  OF  CONGENITAL   TALIPES 


813 


will,  as  a  rule,  correct  it.  The  more  marked  varieties  must  be 
treated  like  the  varus  deformity  of  ordinary  club-foot,  by  braces  or 
by  the  plaster  bandage,  until  the  varus  has  been  transformed  into 
valgus.  The  after-treatment  is  the  same  as  that  for  ordinary, 
club-foot. 

Congenital  Talipes  Equinus. — This  is  a  rare  congenital  deformity, 
about  half  as  common,  according  to  the  statistics,  as  varus  (49 
cases  in  2103).  The  term  equinus  implies  that  dorsal  flexion  is 
limited,  but  that  the  foot  is  not  deviated  to  one  or  the  other  side 
(toward  valgus  or  varus) .  In  congenital  equinus  the  deformity  is, 
as  a  rule,  slight,  and  in  many  instances  it  may  be  overcome  by  gentle 
manual  force  applied  frequently.  In  the  more  resistant  type 
mechanical  correction  or  tenotomy,  followed  by  overcorrection  and 
support,  may  be  necessary. 


Fig.  645. — Congenital  calcaneovalgus. 


Congenital  Talipes  Calcaneus. — Congenital  calcaneus  is  com- 
paratively rare  (47  cases  in  2103).  As  a  rule  the  heel  is  prominent, 
the  foot  is  habitually  dorsiflexed,  and  the  dorsum  can  be  easily 
brought  into  contact  with  the  crest  of  the  tibia  (Fig.  645).  The 
exaggerated  cavus  that  is  usually  present  in  acquired  calcaneus  is 
absent.  Occasionally  the  deformity  is  accompanied  by  hyper- 
extension  of  the  knee;  and  if,  in  many  instances,  there  is  a  history 
of  breech  presentation,  it  may  be  inferred  that  the  attitude  before 
birth  was  one  of  extreme  flexion  of  the  thighs  upon  the  abdomen, 
the  anterior  surfaces  of  the  extended  legs  being  pressed  closely  to 
the  ventral  surface  of  the  body,  the  feet  being  fixed  in  an  attitude  of 


814  DEFORMITIES  OF   THE  FOOT 

dorsiflexion.  As  a  rule  the  deformity  is  slight,  and  the  resistance 
of  the  tissues  on  the  anterior  aspect  of  the  leg  can  be  easily  over- 
come by  massage  and  manipulation.  The  foot  should  be  gently 
forced  toward  plantar  flexion  several  times  in  the  day,  and  the  weak 
muscles  of  the  calf  should  be  stimulated  by  massage. 

Cure  may  be  hastened  by  the  use  of  some  simple  form  of  retention 
splint  to  hold  the  foot  in  plantar  flexion  until  the  posterior  group  of 
muscles  has  recovered  its  power.  Tenotomy  or  other  operative 
treatment  is  not  often  required. 

In  rare  instances  the  tibia  may  be  bent  slightly  backward,  thus 
increasing  the  deformity.  In  such  cases  the  distortion  of  the  bone 
may  be  overcome  by  manipulation  and  by  apparatus. 

Congenital  Talipes  Valgus. — Congenital  valgus  (Fig.  595)  is 
somewhat  more  common  than  the  preceding  varieties  (144  in  2103). 
Not  infrequently  it  is  combined  with  a  slight  degree  of  calcaneus 
or  equinus.  The  resistance  of  the  contracted  tissues  is  not  great, 
and  the  deformity  may  be  overcome,  in  most  cases,  by  persistant 
manipulation.  If  the  muscular  power  is  sufficiently  unbalanced 
to  warrant  it  the  foot  should  be  fixed  in  the  overcorrected  position 
(varus)  for  a  time. 

Congenital  valgus  is  one  form  of  what  is  known  as  weak  ankle, 
and  it  frequently  passes  unnoticed  until  the  child  begins  to  walk. 
If  at  that  time,  in  spite  of  massage,  the  muscles  appear  weak  or  if 
the  foot  inclines  outward  when  weight  is  borne  it  is  well  to  make  the 
sole  of  the  shoe  wedge-shaped,  the  thicker  part  (one-quarter  of  an 
inch)  on  the  inner  side.  In  more  persistant  cases  a  brace  may  be 
necessary,  as  described  in  the  treatment  of  the  acquired  variety. 
(See  Weak  Foot.) 

Talipes  Equinovalgus  is  less  common  (35  in  2103).  This  must 
be  treated  as  the  other  varieties  by  complete  overcorrection  of 
deformity,  manual  or  otherwise,  and  by  subsequent  massage  and 
support  if  necessary. 

Calcaneovalgus  (87  in  2103),  Calcaneovarus  (10  in  2103),  Equino- 
cavus  (1  in  2103),  Valgocavus  (1  in  2103),  Cavus  (5  in  2103),  are 
extremely  rare,  as  indicated  by  the  statistics.  If  treated  early  by 
persistant  massage  supplemented  by  retention  apparatus,  these,  as 
well  as  nearly  all  slighter  grades  of  congenital  deformity,  may  be 
corrected  and  cured  even  before  the  child  begins  to  walk. 

CONGENITAL  DEFORMITIES  OF  THE  FOOT  ASSOCIATED  WITH 
DEFECTIVE  DEVELOPMENT. 

Talipes  Equinovalgus  Associated  with  Congenital  Absence  of 
the  Fibula. — This  is  a  rare  deformity,  but  the  most  common  of 
this  class.  The  foot  at  birth  is  usually  in  an  attitude  of  well-marked 
and  resistant  equinovalgus.  The  leg  is  somewhat  shorter  than  its 
fellow,  and  the  tibia  is  often  bent  sharply  forward,  sometimes  to  an 


CONGENITAL  DEFORMITIES  OF   THE  FOOT 


815 


acute  angle,  at  a  point  somewhat  below  the  centre,  as  if  it  had  been 
broken.  At  the  most  prominent  point  the  skin  may  be  adherent  or 
it  may  present  a  dimpled  appearance.  In  some  instances  the  for- 
mation of  the  foot  is  perfect,  but  more  often  one  or  more  of  the  outer 
toes,  with  the  corresponding  metatarsal  bones,  are  absent  (Fig.  647). 
Statistics. — Haudek  collected  from  the  literature  97  cases.  Of 
these  46  were  in  males,  21  were  in  females,  and  in  30  the  sex  was  not 
recorded.  In  67  (69  per  cent.)  there  was  total  absence  of  the  fibula. 
In  30  the  defect  was  partial;  of  the  lower  extremity  of  the  fibula  in 
17,  of  the  upper  extremity  in  9,  and  of  the  middle  in  2  cases.  In  27 
cases  both  fibulae  were  absent  or  defective,  in  68  one  only — the  right 


Fig.  646. — Congenital  equinovarus,  with  deformity  of  the  great  toes. 

in  31,  the  left  in  25,  and  in  the  others  the  side  was  not  recorded.  In 
61  cases  toes  were  lacking,  and  in  these  cases  it  may  be  inferred  that 
the  corresponding  metatarsal  bones  were  absent  also.  The  fourth 
and  fifth  toes  were  absent  in  27  cases;  the  little  toe  alone  was  missing 
in  15.  In  many  instances,  as  is  usual  in  cases  of  defective  develop- 
ment, deformity  of  other  parts  was  present;  for  example,  in  17 
instances  the  patella  was  absent  or  undeveloped  and  in  1 1  the  upper 
extremities  were  defective.^ 


1  Cotton  and  Chute:  Boston  Med.  and  Surg.  Jour.,  1898,  Nos.  8  and  9  (128  cases). 
Mazzitelli:  Arch.  Ortopedia,  1898,  F.  5.  Boinet:  Rev.  d'Orthop.,  November,  1899. 
Vide  also  Emil  Hain  (113  cases) :  Arch.  Orthop.  Mechanicotherapie  und  Unfal  Chir., 
1903,  Band  i,  Heft  1. 


816 


DEFORMITIES  OF   THE  FOOT 


Etiology. — The  cause  of  deformity,  associated  with  absence  of 
bone,  may  be  either  an  original  defect  in  the  germ  or  it  may  be  due 
to  interference  with  its  development.  In  some  instances  amniotic 
adhesions  may  be  one  of  the  predisposing  causes ;  the  sharp  bend  in 

the  tibia,  so  often  present,  may 
be  due  to  the  lessened  resistance 
of  the  defective  part. 

Treatment.  —  The  indications 
for  treatment  are  to  correct  the 
deformity  of  the  foot  in  the  usual 
manner.  The  bend  in  the  tibia 
may  be  straightened  by  manipu- 
lation and  splinting,  or  by  oste- 
otomy if  necessary.  When  the 
patient  begins  to  walk  the  foot 
must  be  supported.  A  light  steel 
upright  on  the  outer  side  of  the 
leg,  provided  with  a  T-strap  to 
hold  the  leg  against  it,  will  supply 
the  place  of  the  missing  fibula. 
As  the  growth  of  the  tibia,  and 
in  less  degree  that  of  the  femur, 
is  retarded  a  final  shortening  of 
three  or  more  inches  may  be  ex- 
pected. 

Talipes  Varus  or  Equinovarus 
Associated  with  Congenital  Ab- 
sence of  the  Tibia. — Defective 
formation  of  the  tibia  is  much 
less  common  than  that  of  the 
fibula.  Myers^  has  collected  40 
cases.  Of  the  38  cases  in  which 
the  sex  was  recorded,  25  were  in 
males  and  13  in  females.  In  31 
instances  the  defect  was  of  one 
side;  in  17  both  tibipe  were  de- 
fective. In  most  of  the  cases  the 
femiu"  was  somewhat  shortened 
and  its  lower  extremity  was  im- 
perfectly developed.  In  a  third 
of  the  cases  the  patella  was  ab- 
sent, and  in  many  instances 
other  malformations  were  pres- 
ent. In  nearly  all  the  cases  there  was  flexion  contraction  at  the 
knee  and  the  fibula  was  dislocated  backward.     The  foot  is  prac- 


FiG.  647. — Defective  formation  of  the 
lower  limb,  with  absence  of  fibula.  At 
the  age  of  five  years,  the  difference  in  the 
length  of  the  limbs  was  4f  inches.  At 
fourteen  years  the  defective  limb  was 
7  inches  shorter,  the  deficiency  being 
equally  divided  between  the  tibia  and  the 
femur. 


1  Med.  Rec,  July  15,  1905. 


CONGENITAL  DEFORMITIES  OF   THE  FOOT 


817 


tically  always  in  an  attitude  of  varus.  The  toes  may  be  normal, 
but  in  a  number  of  instances  the  great  toe  is  lacking.  In  possibly 
a  third  of  the  cases  a  portion  of  the  tibia,  usually  the  upper  ex- 
tremity, is  present.^ 


Fig.  648. — Congenital  absence  of  fibula. 

The  prognosis  as  regards  a  useful  limb  is  extremely  bad.  The 
growth  of  both  the  thigh  and  the  leg  is  much  retarded,  and  it  is 
almost  impossible  to  balance  the  foot  upon  the  fibula  by  any  form 
of  brace. 


1  Lanois  and  Kuss  report  40  cases. 
52 


Rev.  d'Orthop.,  November,  1901. 


818 


DEFORMITIES  OF   THE  FOOT 


The  ordinary  treatment,  after  the  correction  of  the  deformity  of 
the  foot,  has  been  to  resect  the  extremities  of  the  femur  and  the 
fibula  to  induce  anchylosis.  Xo  final  results  have  been  reported, 
but  it  miay  be  assumed  that  an  artificial  limb  would  provide  a  more 
useful  support  than  the  short  and  distorted  extremity. 

Congenital  Deficiency  and  Hypertrophy. — The  leg  bones  may 
be  perfectly  formed,  but  one  or  more  bones  of  the  foot  itself  may 


Fig.  649. — Congenital   deficiency  of  the 
femur. 


Fig.  650.- 


-Congenital    hypertrophy 
of  the  feet. 


be  absent.  In  these  cases,  after  the  reduction  of  the  deformity, 
a  support  to  hold  the  defective  foot  in  its  proper  relation  to  the  leg- 
must  be  used. 

The  foot  may  be  divided  into  two  parts,  so  that  it  resembles  a 
lobster  cla^^•.  Supernumerary  toes,  or  deficiency  of  toes,  or  hj-per- 
trophy  of  one  or  more  of  the  toes,  with  or  without  corresponding 
overgrowth  of  the  foot  or  leg,  are  not  extremely  uncommon. 


CONGENITAL  DEFORMITIES  OF  THE  FOOT  819 

These  deformities  must  be  treated  on  ordinary  surgical  principles.^ 

Constricting  Bands. — Tightly  constricting  bands  of  scar-like 
tissue,  accompanied  .by  deep  indentations  in  the  flesh  of  the  foot  or 
leg,  are  sometimes  seen.  These  are  supposed  to  be  caused  by  amni- 
otic adhesions.  "Spontaneous  amputations"  of  toes  or  of  the  foot 
itself  are  due  to  the  same  cause  (Fig  598). 

In  ordinary  cases  the  bands  require  no  treatment,  but  if  they 
interfere  with  the  nutrition  of  the  foot  they  may  be  removed. 

Congenital  Hypertrophy  of  the  Feet.^ — In  rare  instances,  some- 
times in  combination  with  deformity,  the  tissues  of  the  feet  are  thick- 
ened and  resistant.  The  condition  is  apparently  due  to  obstruction 
of  the  lymphatic  circulation  (Fig.  650). 

It  should  be  treated  by  massage  and  by  compression. 

Spina  Bifida  and  Talipes. — Talipes  with  spina  bifida  should  be 
treated  as  are  other  forms  of  club-foot.  If  paralysis  of  the  lower 
extremities  be  present,  as  is  often  the  case,  the  corrected  feet  must 
be  supported  as  in  the  ordinary  forms  of  paralytic  deformity. 

1  Klausner:  Ueljer  Missbildungeii  der  nienschlichen  Gliedniasfscn  und  ihre  Entsteh- 
ungsweise,  1900. 


CHAPTER  XXIII. 
DEFORMITIES  OF  THE  FOOT  (Continued). 

ACQUIRED  TALIPES. 

In  the  account  of  the  congenital  deformities  of  the  foot  it  was 
stated  that  equinovarus  was  by  far  the  most  common,  and  that  as 
compared  with  it  the  other  deformities  were  of  sHght  importance. 

In  the  acquired  varieties  of  tahpes  the  equinovarus  deformity  is 
much  less  common,  the  proportion  in  the  congenital  form  being 
77.4  per  cent,  and  in  the  acquired  30  per  cent,  of  the  total  number. 
Acquired  equinus  comes  next  in  frequency,  25.9  per  cent,  as  com- 
pared with  2.3  per  cent,  of  the  congenital  deformity;  and  every 
variety  and  combination  of  distortion  finds  its  representative  in 
acquired  talipes,  as  may  be  seen  in  the  tables.     (See  page  771.) 

Etiology. — ^The  cause  of  acquired  talipes  is  usually  paralysis. 
In  the  table  of  statistics  it  will  be  seen  that  in  79.9  per  cent,  the 
paralysis  was  of  spinal  origin  (anterior  poliomyelitis).  In  11.5  per 
cent,  it  was  cerebral,  the  talipes  being  a  part  of  the  deformity  of 
hemiplegia  or  paraplegia.  In  a  few  cases  the  deformity  was  caused 
by  local  disease  or  by  local  paralysis,  and  the  remainder,  or  7  per 
cent.,  were  of  traumatic  origin. 

The  distinction  between  the  two  varieties  of  talipes,  congenital 
and  acquired,  has  been  emphasized  already.  In  the  congential 
form  the  deformity  is  the  essential  disability,  for  when  deformity 
has  been  corrected  the  most  difficult  part  of  the  treatment  has  been 
accomplished  and  perfect  cure  may  be  expected.  In  the  acquired 
form  the  straightening  of  the  foot  is  but  a  preliminary  part  of  the 
treatment,  for  cure  is  out  of  the  question  except  in  that  small  pro- 
portion of  cases  in  which  the  disease  of  the  spinal  cord  has  caused  no 
permanent  injury  to  its  structure,  or  in  which  the  deformity  was  the 
result  of  some  slight  or  passing  disability  or  of  local  disease  or  injury. 
Congenital  talipes  cannot  be  anticipated  or  prevented.  Acquired 
talipes  is  evidence  that  protective  treatment  has  been  neglected. 
It  is  a  result,  therefore,  that  may  be  foreseen,  and  thus  prevented. 

Development  of  Deformity. — The  characteristics  of  anterior  polio- 
myelitis are  described  elsewhere.  (Chapter  XVII.)  In  its  effect 
upon  the  foot  the  usual  sequence  is  somewhat  as  follows:  At  the 
onset  the  paralysis  is  often  widespread,  affecting  an  entire  limb,  for 
example;  then  follows  a  period  of  partial  recovery,  after  which  the 
amount  of  damage  that  the  spinal  cord  has  sustained  may  be  esti- 
mated.    It  is  during  the  period  of  partial  recovery,  the  six  months 


ACQUIRED   TALIPES  821 

or  more  following  the  attack,  that  deformity  develops.  If,  for 
example,  the  anterior  leg  muscles  are  paralyzed,  the  foot  habitually 
hangs  downward,  an  attitude  induced  by  the  force  of  gravity  and  by 
the  contraction  of  the  active  posterior  group.  If  the  attitude  per- 
sists the  tissues  accommodate  themselves  to  the  new  position;  the 
active  muscles  which  are  never  stretched  to  their  normal  limit 
become  structurally  shortened,  while  the  weakened  or  paralyzed 
muscles  are  correspondingly  lengthened.  Often  within  a  week  or 
two  after  the  onset  of  the  paralysis  the  evidences  of  progressive 
deformity  are  plain.  The  contracted  tissues  resist  passive  motion 
in  the  directions  opposed  to  the  habitual  attitude,  and  the  child 
shows  evidence  of  pain  if  force  is  used  to  increase  the  limited  range 
of  motion.  As  has  been  stated  already,  acquired  talipes  is  an 
unnecessary  deformity.  It  may  be  prevented  by  supporting  the 
paralyzed  foot  in  a  right-angled  relation  to  the  limb,  or  by  sys- 
tematic passive  movements  throughout  the  entire. range  of  normal 
motion. 

Anterior  poliomyelitis  is  most  common  during  the  second  and 
third  years  of  life,  or  when  the  child  has  already  begun  to  walk. 
When  the  first  or  more  general  effect  of  the  disease  has  passed  the 
child  again  uses  the  disabled  limb  as  best  it  may;  thus  the  distor- 
tion of  the  foot  is  increased  and  confirmed  by  the  weight  of  the  body 
and  by  functional  use  in  the  abnormal  attitude. 

The  final  deformity,  in  a  particular  case,  may  be  predicted  from 
knowledge  of  the  function  of  the  muscles  which  have  been  disabled. 
For  example,  paralysis  of  the  tibialis  anticus,  the  most  powerful 
dorsiflexor  and  invertor  of  the  anterior  group,  must  result  in  equino- 
valgus.  Paralysis  of  the  tibialis  posticus,  the  chief  adductor, 
causes  valgus.  If  the  peroneal  group  is  affected  varus  will  follow. 
Paralysis  of  the  calf  muscle  will  cause  calcaneus.  Paresis  or  paraly- 
sis of  the  entire  anterior  group  will  cause  equinus.  If  all  the  muscles 
are  paralyzed,  what  is  called  a  dangle-foot  is  the  result;  the  atrophied 
member  dangles  with  but  little  tendency  to  deformity  other  than 
equinus  unless  it  is  capable  of  use,  when  it  is  usually  forced  into  an 
attitude  of  varus  or  valgus.     (See  Figs.  512  to  523.) 

A  slight  or  transient  paralysis  may  cause  no  immediate  disability 
and  yet  it  may  induce  deformity  in  later  years.  This  fact  has  been 
mentioned  in  the  etiology  of  the  contracted  foot. 

Differential  Diagnosis  between  Congenital  and  Acquired  Deform- 
ity.— The  history  itself  usually  indicates  the  etiology,  for  deformity 
of  the  foot  at  birth  is  never  overlooked  by  the  mother.  Acquired 
talipes  is  of  slow  development,  and  it  is  practically  always  preceded 
by  disease,  weakness,  or  injury. 

In  paralytic  talipes  (anterior  poliomyelitis)  there  is  evidence  of 
paralysis  in  loss  of  function  of  certain  muscles,  as  shown  by  volun- 
tary movements  or  by  pricking  the  foot  with  a  pin;  by  atrophy, 
and  loss  of  growth. 


822  DEFORMITIES  OF   THE   FOOT 

Only  in  neglected  and  extreme  cases  of  talipes  in  the  adolescent 
or  adult  could  there  be  difficulty  in  distinguishing  lietween  the 
acquired  and  the  congenital  deformity.  In  rare  instances,  it  is 
true,  paralysis  may  be  present  at  birth,  due  to  intra-uterine  disease 
or  to  defect  in  the  nervous  apparatus.  In  such  cases  the  cause  of 
the  paralysis  is  usually  apparent  (spina  bifida  or  spastic  paralysis 
associated  with  defective  cerebral  development),  and  the  treatment 
does  not  differ  from  that  of  the  acquired  form. 

ACQUIRED  TALIPES  EQUINUS. 

In  well-marked  equinus  the  foot  is  plantar  flexed  to  its  full  limit, 
and  it  is  fixed  in  this  attitude  by  the  shortened  structures  of  which 


Fig.   651. — Acquired  talipes  equinus,  showing  the  Hmit  of  doi'sal  flexion. 

the  tendo-x4chillis  is  the  most  important.  The  patient  walks  upon 
the  heads  of  the  metatarsal  bones,  the  toes  being  dorsiflexed  to 
accommodate  the  deformity.  The  arch  of  the  foot  is  increased  in 
depth  and  the  tissues  of  the  sole,  particularly  the  plantar  fascia, 
are  contracted.  The  foot  is  broadened  and  shortened,  the  breadth 
being  especially  increased  at  the  anterior  metatarsal  region  (Fig. 
593) .  Corresponding  to  the  exaggerated  depth  of  the  arch,  the  dor- 
sum projects,  the  cuneiform  bones  are  prominent,  and  the  head  and 
body  of  the  displaced  astragalus  may  be  felt  beneath  the  skin  on  the 
anterior  surface  of  the  foot.  In  the  slighter  degrees  of  the  deformity, 
when  the  patient  still  walks  upon  the  sole  of  the  foot,  the  toes  are 
usually  dorsiflexed — an  attitude  due  apparently  to  the  overaction 
of  the  extensor  longus  digitoriun  and  proprius  hallucis,  as  aids  in 
dorsiflexion  (Fig.  651).     In  rare  instances,  and  only  in  those  cases  in 


ACQUIRED   TALIPES  EQUINUS 


823 


which  all  the  anterior  muscles  are  paralyzed,  the  toes  may  be 
plantar  flexed  the  patient  walking  upon  their  dorsal  surfaces. 

The  cavus  or  increased  depth  of  the  arch  is  due  primarily  to  the 
plantar  flexion  of  the  forefoot  at  the  mediotarsal  joint,  and  in  many 
instances  this  dropping  of  the  forefoot  is  in  great  degree  responsible 
for  the  equinus;  in  fact,  the  os  calcis  is  rarely  plantar  flexed  to  the 
degree  commonly  found  in  the  ordinary  congenital  equinus. 

The  cases  of  slight  equinus 
combined  with  cavus  have  been 
described  already  under  the  title 
of  the  Contracted  Foot  (page  728) . 

Etiology. — Equinus  is  the  most 
common  of  the  forms  of  talipes 
acquired  in  later  life.  Anterior 
poliomyelitis,  although  the  usual 
cause,  is  by  no  means  as  impor- 
tant in  the  etiology  of  this  as  of 
other  varieties  of  deformity. 
The  nerve  supply  of  the  anterior 
muscles  of  the  foot  seems  to  be 
particularly  susceptible,  and  toe- 
drop,  from  neuritis  of  various 
types,  is  not  uncommon. 

Equinus  may  be  a  result  of 
disease  or  injury  of  the  brain,  or 
even,  in  rare  instances,  of  pro- 
gressive muscular  dystrophy,  loco- 
motor ataxia,  and  the  like.  It  is 
sometimes  induced  by  habitual 
posture,  as  by  long  confinement  in 
bed  for  the  treatment  of  fracture 
or  during  the  treatment  of   hip 

disease  by  apparatus.  Or  the  contraction  may  be  an  effect  of  vol- 
untary posture,  as  when  the  patient  habitually  walks  upon  the  toes 
because  of  a  short  limb.  It  is  a  very  common  sequel  of  neglected 
disease  at  the  ankle-joint,  and  it  may  be  a  result  of  direct  injury, 
as  for  example  Pott's  fracture. 

The  changes  in  the  internal  structure  of  the  foot  are  similar  to 
those  that  follow  other  forms  of  deformity;  the  tissues  on  the  long 
side  are  lengthened  and  attenuated,  while  those  on  the  short  side 
become  contracted.  The  bones  themselves  are  but  little  changed  in 
gross  appearance,  but  the  articulating  surfaces  are  in  abnormal 
relation  to  one  another;  for  example,  only  the  posterior  part  of  the 
astragalus  may  be  contained  within  the  malleoli  in  relation  to  the 
tibia,  while  only  the  lower  part  of  its  anterior  surface  articulates 
with  the  navicular.  In  all  cases  of  equinus  there  is  a  strong  ten- 
dency toward  varus  or  valgus.  This  is  especially  noticeable  in  those 
of  paralytic  origin. 


Fig.     652.  —  Tuberculous    "rheuma- 
tism" and  equinus  deformity. 


824  DEFORMITIES  OF   THE  FOOT 

Symptoms. — The  effects  of  the  deformity  vary.  If  the  Hmb  is 
actually  shorter  than  its  fellow,  so  that  the  lengthening  caused  by 
the  extension  of  the  foot  is  no  more  than  a  sufficient  compensation, 
and  if  the  foot  is  firmly  fixed  in  the  deformed  position^  there  is  but 
little  disability,  and  the  chief  discomfort  is  from  corns  or  calluses 
beneath  the  metatarsal  bones. 

If  the  limb  is  not  shorter,  the  additional  length  caused  by  the 
equinus  must  be  compensated  by  a  tilting  of  the  pelvis  and  lateral 
deviation  of  the  spine.  This  often  causes  discomfort  in  the  lumbar 
region.  The  gait  m  this  class  of  cases  is  always  awkward,  giving 
the  impression  as  of  stepping  over  an  obstacle. 

If  the  foot  is  not  fixed  in  the  attitude  of  equinus — that  is,  if  it 
hangs  doT\'nward  durmg  progression — the  gait  is  very  awkward, 
because  of  the  insecurity  and  because  of  the  exaggerated  flexion  at 
the  knee  necessary  to  lift  the  pendant  foot. 

If  the  equinus  is  extreme  the  limb  is  usually  flexed  at  the  knee 
when  in  use.  If  it  is  so  slight  that  the  foot  may  be  used  in  the 
plantigrade  position,  the  strain  resulting  from  the  Imiitation  of 
dorsal  flexion  is  felt  at  the  knee;  and  in  childhood  especially  there 
is  often  a  well-marked  tendency  to  OA'erextension  or  recm-vation, 
caused  by  the  effort  to  place  the  heel  upon  the  ground. 

In  the  slight  degrees  of  equinus,  discomfort  about  the  calf  is 
experienced;  the  limitation  of  dorsal  flexion  causes  a  shortened 
stride  and  awkward  gait,  while  an  unguarded  step  that  throws  a 
sudden  strain  upon  the  resistant  heel  cord  is  felt  as  a  shock  and  strain 
through  the  limb.  Very  often  the  patient  complains  of  pam  about 
the  metatarsal  bones  (anterior  metatarsalgia),  and  if  the  equinus  is 
accompanied  by  a  slight  degree  of  valgus,  as  is  not  uncommon, 
s^Tnptoms  of  the  weak  foot  may  be  present. 

The  prognosis  as  to  permanent  cure  depends,  of  course,  upon  the 
cause  of  the  deformity.  When  it  is  simply  the  result  of  posture  or 
of  the  ordinary  form  of  neuritis  and  the  like  complete  cure  may  be 
expected.  In  many  of  the  cases  caused  by  anterior  poliomyelitis 
there  has  been  recovery,  complete  or  partial,  of  the  original  injury 
to  the  spinal  centres.  But  although  the  power  has  been  regained, 
it  carmot  be  exercised  because  the  foot  is  held  in  the  distorted  posi- 
tion by  the  contracted  tissues.  In  such  instances  practical  cure  may 
be  predicted  if,  after  the  overcorrection  of  deformity,  sufficient  time 
is  allowed  for  the  overstretched  and  atrophied  muscles  to  regain 
their  proper  length  and  vohmie. 

Treatment. — ^In  the  cases  of  fixed  equinus  with  a  shortened  limb 
in  which  the  patient  suffers  no  discomfort  a  shoe  shoifld  be  so  built 
as  to  equalize  the  presstu-e  on  the  bearing  siu-face.  In  the  more 
extreme  cases  in  which  the  limb  is  short  and  the  foot  is  atrophied 
an  "extension"  shoe,  may  be  worn  with  comfort  and  with  but  little 
evidence  of  deformity. 

In  the  ordinary  cases,  whether  cure  is  expected  or  not,  the  rule 


ACQUIRED   TALIPES  EQUINUS  825 

holds  good  that  the  heel  should  bear  weight,  and  that  the  range  of 
dorsal  flexion  should  not  be  limited  when  the  calf  muscle  retains  its 
power.  If  the  paralysis  is  permanent  the  foot  must  be  supported 
after  the  deformity  has  been  corrected;  but  even  in  this  class  the 
gait  may  be  improved  and  the  discomfort  may  be  relieved  by  remov- 
ing the  restrictions  to  normal  motion. 

The  slight  degrees  of  equinus  in  young  subjects  may  be  overcome 
by  simple  manipulation  or  by  elastic  tension,  or  by  retention  in  a 
splint  or  in  a  plaster  bandage.  If  the  foot  is  fixed  by  a  plaster 
splint  at^a  right  angle  to  the  leg  it  Mall  be  found  after  a  few  weeks 
that  the  range  of  dorsal  flexion  has  been  increased  by  functional 
use.  Manual  stretching  of  the  contracted  tissues  is  also  of  service; 
for  example,  the  patient  being  seated  extends  the  limb ;  the  surgeon 
stands  in  front  of  him,  one  hand  holds  the  leg  firmly  at  the  ankle, 
and  the  other  grasps  the  foot,  which  is  then  dorsiflexed  over  and 
over  again  with  as  much  force  as  is  consistent  with  the  comfort  of 
the  patient. 

Certain  forms  of  apparatus,  for  example,  the  Shaffer  exten- 
sion shoe,  may  be  employed  with  advantage  in  cases  of  slight 
deformity. 

Immediate  Correction  of  Deformity. — Attention  has  been  called  to 
the  cavus  as  a  secondary  deformity  that  usually  accompanies 
equinus,  and  in  operative  correction  the  exaggerated  arch  should 
first  be  reduced  to  its  normal  depth,  otherwise  the  foot  will  appear 
stunted  and  deformed. 

One  of  the  most  effective  procedures  is  forcible  reduction  by  means 
of  the  Thomas  wrench  (Fig.  629).  The  contracted  bands  of  the 
plantar  fascia  are  first  divided  subcutaneously,  the  wTench  is  then 
fixed  to  the  foot,  and  by  sudden  force  exerted  against  the  resistant 
tendo-Achillis  the  foot  is  straightened,  the  shortened  tissues  being 
ruptured  or  stretched  to  the  proper  degree.  The  resistance  to 
normal  dorsal  flexion  is  then  overcome  by  manual  force,  or,  if  neces- 
sary, by  subcutaneous  division  of  the  tendo-Achillis,  and  the  foot  is 
fixed  by  a  plaster  bandage  in  an  attitude  of  dorsiflexion.  If  as 
is  usual  the  toes  are  contracted,  the  deformity  should  be  reduced  in 
the  manner  already  described.     (See  Contracted  Foot.) 

As  the  patient  is  encouraged  to  walk  upon  the  foot  as  soon  as 
possible,  the  weight  of  the  body  forcing  the  relaxed  tissues  against 
the  plaster  sole,  reinforced,  if  necessary,  by  a  wooden  foot  plate 
completes  the  flattening  of  the  arch.  In  many  of  these  cases  the 
knee  has  been  overextended  by  use  in  the  deformed  attitude,  so 
that  the  habitual  flexion  necessary  to  bring  the  dorsiflexed  foot  upon 
the  ground  during  the  two  months  required  for  the  complete  union 
of  the  divided  tendon  is  of  beneflt,  as  it  serves  to  correct  this  sec- 
ondary weakness  and  deformity. 

The  Tonic  Effect  of  Immediate  Correction. — ^The  impor- 
tance of  the  tonic  effect  of  immediate  relief  of  the  strain  of  the 


826 


DEFORMITIES  OF   THE  FOOT 


deformed  position  upon  the  weak  anterior  gronp  of  muscles^  together 
with  the  complete  relaxation  of  the  overstretched  tissues,  during 
the  long  rest  in  the  overcorrected  position  is  not  generally  appreci- 
ated. Whenever  the  weakened  muscles  after  paralysis  show^  by 
tests,  electrical  or  otherwise,  that  they  have  recovered  their  power 
in  part,  overcorrection  of  the  deformity  is  indicated.  The  applica- 
tion of  electricity  or  other  form  of  stimulation  to  muscles  that  are 
unable  to  exercise  their^  function  because  of  contraction  of  the 
opposing  tissues  is  useless;  nor  is  any  other  form  of  artificial  stimu- 


FiG.  653. — A  brace  with  a  "limited" 
joint,  permitting  slight  motion  at  the 
ankle. 


Fig.  654. — A  brace  with  "stop" 
joint  to  prevent  foot-drop.  One  up- 
right is  often  sufficient. 


lation  equal  to  functional  use,  which  is  made  possibly  by  the 
reduction  of  the  deformit}'  and  support  in  the  proper  attitude. 
Equinus,  more  often  than  any  other  deformity,  is  the  result  of  slight 
or  temporary  disability  of  the  anterior  group  of  muscles,  and  not 
infrequently  perfect  ciue  seems  to  have  been  attained  when  the 
plaster  splint  is  finally  removed,  usually  at  the  end  of  tW'O  months 
or  more;  but  even  in  such  cases  the  application  of  a  simple  support 
to  hold  the  foot  at  a  right  angle  with  the  leg  for  several  months  is 
advisable,  while  a  lighter  brace  to  hold  the  foot  dm'ing  the  night  in 
the  original  attitude  of  overcorrection  is  an  effective  means  of  pre- 
^-enting  relapse.     The  after-treatment  by  massage,  muscle-training, 


ACQUIRED   TALIPES  EQUINUS 


827 


electricity,  and  tlie  like,  combined  with  methodical  passive  move- 
ments to  the  limit  of  dorsal  flexion  to  guard  against  recontraction 
of  the  calf  muscle,  should  be  continued  for  a  long  time  or  imtil  the 
muscular  balance  has  been  regained. 

Support  is,  usually,  necessary',  in  cases  of  permanent  paralysis, 
to  hold  the  foot  at  a  right  angle  with  the  leg.  The  common  form 
is  a  simple  steel  sole  plate  of  sufficient  size  to  support  the  sole  and 
the  toes,  also,  if  their  muscles  are  paralyzed,  attached  to  a  light 


Fig.  655. — An  effective  and  inconspicuous  support  for  paralytic  toe-drop.  An 
upright  of  light  tempered  steel,  carefully  adjusted  to  the  inner  side  of  the  leg  and 
ankle,  provided  with  a  light  calf  band.  This  is  strengthened  by  a  posterior  support 
attached  to  the  upright.  The  lower  end  of  the  brace  is  arranged  as  a  caliper  and  is 
fitted  to  the  metal  disk,  of  which  two  views  ai'e  shown.  A  depression  is  cut  in  the 
heel  of  the  shoe  for  the  disk,  as  is  shown  in  the  diagram.  Two  strong  elastic  tapes 
are  sewed  to  the  leather  of  the  shoe.  These  are  attached  to  the  studs  on  the  front  of 
the  calf  band,  and  thus  the  toe-drop  is  prevented.     (See  Fig.  656.) 


upright,  provided  with  a  calf  band.  The  upright  is  usually  applied 
on  the  inner  side  of  the  leg,  where  it  is  least  noticeable.  At  the 
ankle  there  is  a  "stop  joint,"  which  permits  dorsiflexion  but  pre- 
vents the  toe-drop.  This,  when  properly  fitted,  can  be  placed 
inside  the  ordinary  shoe,  as  the  paralyzed  foot  is  usually  somewhat 
smaller  than  its  fellow  (Fig.  654) .  If  the  toes  do  not  need  support, 
the  upright  can  be  attached  to  the  outside  of  the  shoe  and  the  foot 
plate  may  be  dispensed  with;  or,  the  upright  may  be  concealed  by 
introducing  it  inside  the  shoe  to  a  joint  sunk  in  the  heel,  the  toe- 


828 


DEFORMITIES  OF   THE  FOOT 


dro])  beino-  prevented  1)y  straps  passing  from  the  front  of  the  upper 

leather  of  the  shoe  to  the  calf  band  (Fig.  655). 

Operative  Treatment. — The  operative  treatment  of  drop-foot  is 

from  the  stand-point  of  complete  relief  rather  disappointing. 

Silk  Ligaments. — ^These  are  of  temporary  value,  but  when  sup- 
port is  remo\'ed  the  deformity  often  recurs. 

Tendon   Implantation. — This    is    at    a   mechanical    disadvantage 

because  there  is  no  tendon  on  the  outer  border  of  the  foot  available 

to  balance  the  tibialis  anticus. 
Gallic  displaces  the  peroneus 
longus  forward  and  inserts  its 
tendon  through  a  hole  bored 
in  the  fibula  in  an  anteropos- 
terior direction.  This  is, 
however,  only  practicable  if 
the  muscle  is  paralyzed. 

Tendon  Displacem.ent.  —  I 
have  displaced  the  tendons  of 
the  peroneus  brevis  and  the 
tibialis  anticus  from  their  at- 
tachments behind  the  malleoli 
upward  to  a  point  about  three 
inches  above  the  malleoli  so 
that  passing  forward  and 
downward  these  may  ser^•e  to 
restrain  plantar  flexion  in 
some  degree. 

Arthrodesis.  —  This  opera- 
tion may  induce  right  angular 
anchylosis,  but  this  is  a  dis- 
advantage if  the  limb  is 
short,  and  in  any  eveiit 
anchylosis  is  undesirable  if 
many  of  the  muscles  are 
active. 

Astragalectomy  and  Back- 
ward Displacement. — This  is 
useful  in  cases  of  dangle-foot, 

especially  if  accompanied  by  lateral  deformity,  but   it   is  rarely 

indicated  for  simple  equiiuis. 


Fig.  656. — The  same  appliance  (Fig.  655) 
pro^•ided  -n-ith  a  foot-plate  of  metal  or  of  wood 
as  shown  in  the  diagram.  This  modification 
is  useful  if  the  paralj-sis  is  complete  or  if  the 
foot  is  much  atrophied. 


ACQUIRED  TALIPES  EQUINO VARUS. 

Talipes  equinovarus  is,  in  the  acquired  as  in  the  congenital  form, 
the  most  common  of  the  deformities  of  the  foot  (Fig.  598) . 

The  tendency  of  simple  equinus  is  usually  toward  varus,  because 
in  plantar  flexion  the  foot  is  slightly  adducted  and  because  the  outer 


ACQUIRED   TALIPES  EQUINOVARUS 


829 


side  of  the  foot  is  shorter  than  the  inner  side,  so  that  in  walking  with 
the  foot  extended  the  tendency  of  the  foot  is  to  turn  somewhat 


Fig.  657. — Support  and  elevation  after  arthrodesis. 


Fiti.  658. — Silk  ligaments  applied  to  restrain  plantar  flexion.      (See  page  856.) 


inward.     Equinovarus  is  usually   preceded  by  equinus,   and  the 
etiology  of  the  one  will  serve  for  the  other  (page  822) . 

In  certain  cases  the  varus  is  more  marked  than  the  equinus,  as, 


830 


DEFORMITIES  OF   THE  FOOT 


for  example,  when  the  abductors  of  the  foot  are  paralyzed  while 
the  adductors  retain  their  power;  or  in  cases  of  direct  injury,  as  in 
fracture  at  the  ankle;  or  when  the  growth  of  the  tibia  has  been 
arrested,  as  the  result  of  injury  or  disease. 

A  detailed  account  of  the  appearance  and  efi'ect  of  the  deformity 
is  unnecessary. 

Treatment. — If  the  deformity  is  resistant  it  should  be  reduced 
and  overcorrected  by  forcible  manipulation  under  anesthesia. 
Division  of  resistant  parts  is  less  often  necessary  than  in  the  con- 
genital form,  but  it  may  be  required  in  neglected  cases.  The  over- 
corrected  position  should  be  retained  until  sufficient  time  has  been 
allowed  for  the  reconstruction  of  the  lengthened  tissues;  for,  as 
has  been  mentioned  in  the  treatment  of  equinus,  fixation  in  the  over- 
corrected  position  is  by  far  the  most  efi^ective  treatment  that  can  be 


Fig.  659. — A  trace  for  equinovalgus  deformity.     The  author's  brace  for  weak  foot 
combined  ^ith  an  upright  -n-ith  a  stop  joint  to  prevent  plantar  flexion. 


applied  to  a  weak  or  paralyzed  part.  The  foot  must  then  be  sup- 
ported by  a  brace,  of  which  the  Taylor  club-foot  apparatus  is  the 
t^'pe  (Fig.  616).  Tendon  implantation,  after  the  Gallic  method,  of 
the  two  peroneii  into  gi'ooves  cut  in  the  fibula  is  eifective  in  restrain- 
ing deformity,  and  silk  ligaments  are  used  for  the  same  purpose. 

Transplantation  of  half  of  the  tendon  of  the  tibialis  anticus  ten- 
don or,  if  the  tibialis  posticus  is  active,  the  entire  tendon  to  the 
periosteum  or  bone  of  the  outer  border  of  the  foot  near  the  base  of 
the  fifth  metatarsal,  combined  with  artlirodesis  of  the  astragalo- 
na"\dcular  articulation  in  an  attitude  of  slight  abduction  or  of  the 
subastragaloid  articulation,  as  suggested  by  Davis,  is  of  service  as  a 
curative  procedure.  Transplantation  of  the  tibialis  posticus  to  the 
attaclmient  of  the  peroneus  brevis,  or  to  its  tendon  behind  the 
external  malleolus,   is   also  indicated  in   certain  instances.      (See 


ACQUIRED   TALIPES  EQUINOVALGUS  831 

Tendon  Transplantation.)  If  the  deformity  is  of  long-standing  the 
removal  of  a  sufficient  wedge  of  bone  from  the  outer  border  of  the 
tarsus  to  permit  overcorrection  may  be  indicated.  This  should  be 
combined  with  tendon  implantation  or  transplantation.  Astragalec- 
tomy  and  backward  displacement  of  the  foot  is  most  effective  in  the 
cases  in  which  the  paralysis  is  complete,  or  in  those  cases  in  which 
the  varus  is  accompanied  by  cavus. 

ACQUIRED  TALIPES  EQUINOVALGUS. 

Acquired  talipes  equino valgus  is  much  less  frequent  than  the  pre- 
ceding deformity.  Simple  equinovalgus  is  usually  the  result  of 
primary  paralysis  of  the  tibialis  anticus,  the  most  powerful  of  the 


Fig.  660. — Tendon  implantation.  All  the  structures  have  been  removed  from 
the  skeleton  except  the  tibialis  anticus  muscle  and  tendon  which  has  been  buried 
in  the  tibia  to  prevent  foot-drop.    The  stitches  are  shown.    (Gallie.)    (See  page  857.) 

dorsal  flexors;  thus  the  foot  is  drawn  somewhat  outward  when 
dorsiflexed,  while  the  metatarsal  bone  of  the  great  toe,  having  lost 
its  support  falls  downward  and  is  drawn  outward  by  the  peroneus 
longus.  In  this  type  one's  attention  is  often  attracted  to  the 
peculiar  appearance  of  the  great  toe,  which  is  deformed  somewhat 
like  a  hammer-toe  by  the  overaction  of  the  extensor  longus  hallucis 
in  its  attempt  to  take  the  place  of  the  tibialis  anticus.  The  equinus 
is  usually  slight  and  is  secondary  to  the  valgus.  Treatment  may  be 
begun  by  placing  the  foot  in  a  plaster  bandage  in  an  attitude  of  varus 
and  allowing  the  patient  to  walk  upon  it  until  the  tendency  toward 
deformity  has  been  overcome.  A  support  with  the  catch,  as  for 
toe-drop,  is  applied  to  the  shoe,  and  the  tendency  toward  valgus  is 
checked  by  raising  the  inner  border  of  the  sole  or  by  the  use  of  a  sole 
plate,  as  in  the  treatment  of  the  simple  weak  foot  (Fig.  448).     In 


832 


DEFORMITIES  OF   THE  FOOT 


Fig.  661. — Tendon  of  peroneus  iongus  has  been  fixed  in  anterior  border  of  externa 
malleolus  and  tendon  of  peroneus  bre\as  is  ready  to  be  laid  in  trough  prepared  for  it 
behind  the  malleolus.     (Gallie.) 


Fig.  662. — The  drawing  shows  the  flexor  Iongus  halliicis  retracted  so  as  to  expose 
the  posterior  surface  of  the  tibia.  The  anterior  half  of  the  tendo-Achilhs  has  been 
sewn  into  the  groove  in  the  bone.  The  incision  in  the  sheath  of  the  tendo-Achillis 
has  been  closed  and  the  two  peronei  tendons  have  been  transplanted  into  the  os  calcis. 


ACQUIRED  SIMPLE   TALIPES   VALGUS  833. 

this  class  of  cases  tendon  transplantation,  particularly  the  implanta- 
tion of  the  tendon  of  the  extensor  longus  hallucis  or  longus  digi- 
torium  or  both  in  the  region  of  the  navicular,  or  combined  with 
arthrodesis  of  the  astragalonavicular  articulation  to  fix  the  foot  in 
the  attitude  of  adduction  is  of  service.  If  the  tibialis  anticus 
muscle  is  completely  paralyzed  its  tendon  should  be  implanted  in 
the  tibia  after  the  Gallic  method.  I  have,  however,  found  it  better 
to  make  the  groove  diagonally  across  the  lower  end  of  the  tibia  in 
order  to  hold  the  foot  more  securely  in  varus  and  to  loop  the 
tendon  before  transplantation  about  all  the  other  dorsal  tendons  to 
draw  them  toward  the  inner  border  of  the  foot.  Transplantation 
of  the  peroneus  longus  or  brevis  and  tertius  across  the  front  of  the 
leg  to  the  navicular,  or  the  peroneus  brevis,  behind  the  internal 
malleolus  to  the  tibialis  posticus;  arthrodesis  of  the  subastragaloid 
joint;  or  astragalectomy  with  backward  displacement  of  the  foot  are 
alternative  procedures,  the  last  being  indicated  in  cases  of  marked 
lateral  deformity  associated  with  cavus. 


ACQUIRED  SIMPLE  TALIPES  VALGUS. 

Acquired  simple  talipes  valgus  from  paralysis,  of  the  tibialis 
posticus  is  rare.  The  deformity  may  be  controlled  usually  by  a  flat- 
foot  support  and  proper  shoe.  Talipes  valgus,  in  combination  with 
cavus,  caused  by  complete  paralysis  of  the  leg  muscles,  is  an  occa- 
sional variety  of  dangle-foot. 

Talipes  valgus,  sometimes  called  spurious  valgus,  the  simple 
weak  or  flat-foot,  has  been  described  elsewhere.     (Chapter  XX.) 

Talipes  caused  by  cerebral  disease,  whether  of  the  paraplegic  or 
the  hemiplegic  type,  is  in  early  childhood  almost  always  of  the  form 
of  equinovarus.  In  adolescence  the  deformity  may  be  equinovalgus 
or  even  calcaneo valgus  if  there  is  extreme  flexion  at  the  knee.  The 
hemiplegic  form  of  talipes  is  much  more  rigid  and  unyielding  than 
the  paraplegic  type.  The  treatment  of  spastic  paralysis,  of  which 
the  deformity  is  a  part,  is  discussed  elsewhere.  (Chapter  XVIII.) 
The  deformity  must  be  corrected  by  the  ordinary  methods.  In 
many  instances  when  the  contractions  are  not  marked  mechanical 
treatment  is  unnecessary. 

Traumatic  valgus  and  equinovalgus  caused  by  fracture  at  the 
ankle  (Pott's  fracture)  may  be  treated  by  osteotomy  of  the  tibia 
above  the  ankle.  By  this  means  the  proper  relation  of  the  leg  to 
the  foot  may  be  restored  in  many  instanbes.  Equinovalgus  of  slight 
degree  is  not  uncommon  after  tuberculosis  or  rheumatoid  disease  at 
the  ankle  or  at  the  astragalonavicular  joints.  This  is  practically 
one  variety  of  weak  foot. 

Hysterical  eqinovarus  or  other  form  of  deformity  is  not  especially 
rare.  The  diagnosis  may  be  made  from  the  other  symptoms  of 
53 


834  DEFORMITIES  OF   THE  FOOT 

hysteria,  from  the  history  of  the  onset  and  duration  of  the  distor- 
tion, and  from  the  appearance  of  the  deformity,  which  is  evidently 
merely  an  assumed  posture.     (See  page  658.) 

ACQUIRED  TALIPES  CALCANEUS. 

Talipes  calcaneus  is  much  less  common  than  equinus  and  it 
is  practically  always  of  paralytic  origin,  although  it  occasionally 
follows  rupture  or  division  of  the  tendo-Achillis,  or  injury  or  disease 
about  the  ankle-joint 

Etiology. — There  are  several  varieties  or  grades  of  the  deformity. 
If  all  the  muscles  of  the  posterior  group  have  been  paralyzed,  the 
foot  soon  assumes  an  attitude  of  slight  dorsiflexion,  and  the  range 
of  plantar  flexion  is  gradually  lessened  by  secondary  contractions. 
This  variety  resembles  closely  the  congenital  form  (simple  cal- 
caneus) (Fig.  594).  In  the  ordinary  and  typical  form  of  calcaneus, 
when  fully  developed,  the  patient  walks,  as  the  name  implies,  on 
an  elongated  heel.  The  arch  of  the  foot  is  much  increased  in  depth, 
and  the  forefoot  is  atrophied  and  useless  (calcaneocavus)  (Fig.  668). 

Development  of  Deformity. — The  development  of  the  deformity 
is  somewhat  as  follows:  The  tension  and  support  of  the  calf  muscle 
having  been  lost,  the  position  of  the  os  calcis  changes  and  eventually 
it  tends  to  stand  on  end,  so  that  its  posterior  surface  becomes 
inferior.  The  projection  of  the  heel  is  first  lessened  and  finally 
lost.  The  change  in  the  position  of  the  os  calcis  increases  the 
distance  from  the  malleoli  to  the  base,  deepens  the  longitudinal 
arch,  and  shortens  the  foot;  thus  cavus  is  a  later  complication  of  all 
cases  of  paralytic  calcaneus.  If  the  entire  posterior  group  of  muscles 
is  paralyzed,  while  the  anterior  muscles  are  unaffected,  the  foot  will 
be  somewhat  dorsiflexed  and  the  cavus  will  be  less  marked.  If  the 
calf  muscle  only  (gastrocnemius  and  soleus)  is  paralyzed,  the  remain- 
ing muscles  of  the  posterior  group  will  counter-balance  the  dorsi- 
flexors  and  at  the  same  time  increase  the  cavus.  In  all  cases  the 
range  of  plantar  flexion  is  lessened.  In  many  instances  one  or  more 
of  the  lateral  muscles  is  paralyzed,  in  which  case  the  foot  is 
usually  turned  toward  valgus.  The  changes  primarily  caused  by  the 
paralysis  and  by  unopposed  muscular  action  become  fixed  by  habit- 
ual use  and  by  secondary  adaptation  of  the  tissues.  The  heel  only 
is  used  in  walking,  and  the  area  of  callus  indicating  its  weight-bearing 
surface  becomes  much  enlarged,  and  to  it  forefoot  and  toes  become 
a  mere  appendage,  a  striking  illustration  of  the  atrophy  that  follows 
disuse  (Fig.  668). 

Symptoms. — The  gait  is  shambling,  the  patient,  who  is,  as  it 
were,  "hamstrung,"  stamps  along  upon  the  insecure  heel  in  a  manner 
which  is  easily  recognizable  by  one  familiar  with  the  deformity. 
The  changes  in  the  internal  structure  of  the  foot,  the  inevitable 
adaptations  to  the  deformity,  do  not  call  for  special  description. 


ACQUIRED   TALIPES  CALCANEUS 


835 


Treatment. — When  the  diagnosis  of  paralysis  of  the  calf  muscle 
is  made  one  may  predict,  unless  recovery  takes  place,  a  deformity 


Fig.  663. — -Talipes  calcaneus  in  the  developmental  tstage,  sliowiiifi;  the  atrophy  of  the 

forefoot. 


Fig.  664. — ^Talipes  calcaneus,  showing  the  change  in  the  static  conflitions  that  causes 

the  instability. 


such  as  has  been  described.  This  deformity  may  be  lessened  or 
even  prevented  by  proper  support,  by  massage  and  methodical 
stretching  of  the  tissues  that  have  a  tendency  to  contract.     The 


S36 


DEFORMITIES  OF   THE  FOOT 


form  of  brace  used  for  walking  and  support  should  be  pro\'ided  with 
a  sole  plate,  upright,  and  calf  band,  as  already  described  in  the 


Fig.  665  Fig.  666 

Figs  665  and  666.- — Judson's  brace  for  calcaneus  defomiits'. 


Fig.  667. — The  author's  brace  for  calcaneus  and  lateral  distortions  of  the  foot. 
It  consists  of  two  light  lateral  steel  bars  joined  in  front  above  by  a  padded  band  of 
steel  which  crosses  the  upper  third  of  the  tibia,  and  below  expanded  to  a  narrow 
anterior  sole  plate,  supplemented  by  a  leather  support  for  the  sole.  The  brace  is 
made  on  a  plaster  cast  in  the  attitude  of  slight  plantar  flexion.  The  shoe  is  adjusted 
to  the  inclination  of  the  brace  by  a  cork  wedge  in  the  heel. 


ACQUIRED   TALIPES  CALCANEUS 


837 


treatment  of  paralytic  equiims.  If  motion  is  permitted  at  the  ankle 
it  should  be  in  plantar  flexion  only,  the  stop  being  the  reverse  of 
that  used  in  equinus;  or,  as  this  form  of  check  entails  much  strain 
upon  the  joint,  it  may  be  omitted  (Figs.  665  and  666).  A  still 
stronger  and  more  effective  brace  is  that  shown  in  Fig.  667,  by  which 
the  strain,  removed  from  the  weakened  tissues,  is  borne  by  the 
anterior  surface  of  the  leg.  Other  forms  of  braces  are  sometimes 
employed,  provided  with  elastic  bands  to  supply  the  place  of  the 
calf  muscle;  but,  as  a  rule,  the  improvement  in  gait  hardly  com- 
pensates for  the  difficulty  in  adjustment  or  the  conspicuousness  of 
the  appliance. 


Fig.  668. — Paralytic  calcaneus,  showing  secondary  changes  in  contour. 


The  most  important  part  of  the  actual  deformity  of  calcaneus 
is  the  cavus,  and  in  confirmed  cases  it  is  practically  impossible  to 
reduce  this  directly,  because  the  loss  of  resistance  of  the  tendo- 
Achillis  takes  away  the  point  of  fixation  against  which  effective 
force  can  be  exerted.  If  this  is  not  marked  the  foot  may  be  drawn 
as  far  as  possible  toward  equinus  and  fixed  in  a  plaster  bandage, 
of  which  the  sole  part  is  made  strong  and  unyielding.  Upon  this 
the  patient  may  walk,  the  heel  being  built  up  with  cork  wedges  to 
make  the  sole  level.  When  the  contraction  of  the  anterior  tissues 
has  been  overcome  the  brace  is  applied  and  the  usual  treatment  of 
manipulation  and  massage  is  continued  (Fig.  667), 


838 


DEFORMITIES  OF   THE  FOOT 


The  method  of  prolonged  fixation  in  the  attitude  of  equinus  by 
means  of  the  plaster  splint  is  often  of  value  in  early  childhood,  if  the 
paralysis  is  not  complete,  and  cures  of  apparently  hopeless  cases  by 
this  means  have  been  reported^  (Fig.  674). 

Operative  Treatment. — In  more  extreme  cases  immediate  reduc- 
tion of  the  deformity  under  anesthesia  may  be  attempted.  The  con- 
tracted tissues,  more  particularly  the  plantar  fascia,  may  be  divided 
subcutaneously  or  by  open  incision;  then  by  forcible  manipulation 
on  ^n*enching,  the  sole  may  be  somewhat  lengthened  and  the  heel 
pushed  upward  and  backward  to  permit  of  slight  plantar  flexion. 
In  this  attitude  the  foot  should  be  fixed  by  means  of  a  plaster  splint. 
In  the  reduction  of  the  deformity  one  must  not  merely  force  the 
forefoot  downward,  as  this  would  simply  increase  the  cavus,  but 
whatever  correction  is  accomplished  should  be  by  means  of  elevation 
of  the  OS  calcis  and  elongation  of  the  tissues  of  the  sole  of  the  foot. 

In  cases  of  extreme  deformity  the 
contracted  tissues  in  the  anterior 
aspect  of  tlie  ankle  must  be  divided 
also. 

In  some  instances  the  improved 
position  of  the  os  calcis  may  be  as- 
sured for  a  time  by  shortening  the 
tendo-Achillis,  as  first  performed  by 
Willett,  of  London.- 

Willett's  Operation  for  Calcaneus. — 
A  Y-shaped  incision  about  two  inches 
in  length  is  made  tlii'ough  the  tissues 
down  to  the  tendon.  At  the  lower 
vertical  part  of  the  incision,  which  is 
continued  down  to  the  tuberosity  of 
the  OS  calcis,  the  tendon  is  dissected 
from  the  surrounding  parts.  It  is 
then  divided  in  an  oblique  direction 
from  -^"ithin  outward  and  downward, 
and  the  heel  ha^'ing  been  pushed 
upward  as  far  as  possible  the  divided  ends  are  overlapped  and 
sutured;  the  flap  of  skin  is  drawn  downward  at  the  same  time, 
so  that  the  Y-incision  is  converted  into  the  shape  of  a  V.  Accord- 
ing to  ]Mr.  Willett's  original  directions,  deep  sutiues  are  passed 
through  the  skin  flaps  and  through  the  tendon  on  either  side,  so 
that  all  the  tissues  are  united.  The  foot  is  then  fixed  in  a  plaster 
stipport  in  an  attitude  of  equinus.  As  soon  as  practicable  the  patient 
begins  to  use  the  foot,  wearing  a  high  heel  to  compensate  for  the 
elevation  of  the  sole. 

PaUiati\'e  operations  of  this  class  aside  from  lessening  deformity 

1  Gibney:  Tr.  Am.  Orthop  Assn.,  1900,  xiii. 

2  St.  Bartholomew's  Hosp.  Reports,  1880,  xvi,  .309. 


Fig.  669. — Talipes  calcaneus 
in  early  childhood. 


ACQUIRED   TALIPES  CALCANEUS  839 

may  be  of  service  in  those  cases  in  which  some  power  remains  in  the 
calf  muscle.  In  cases  of  complete  paralysis  the  shortened  tendon 
offers  some  resistance  to  deformity,  but  unless  support  is  used  after- 
ward the  tissues  will  stretch  under  the  strain  of  use ;  thus  the  treat- 
ment should  always  be  supplemented  by  a  brace  of  the  character 
already  described. 

Silk  Ligaments. — This  operation  has  been  generally  abandoned 
as  useless. 

Tendon  Transplantation. — The  original  operation  of  Nicoladoni  of 
transplanting  the  peroneii  tendons  to  the  tendo-Achillis,  or  any  of 
its  modifications,  are  of  limited  value  except  as  adjuncts  to  mechani- 
cal support  since  the  power  in  the  transplanted  muscles  is  insignifi- 
cant in  comparison  to  that  of  the  calf  muscle. 

Tendon  Fixation  and  Transplantation.— Gallic^  combines  tendon 
fixation  and  transplantation.  In  cases  in  which  the  paralysis  of  the 
calf  is  not  complete,  the  tendo-Achillis  is  split  from  side  to  side  and 
the  anterior  half  is  embedded  in  the  tibia.  The  two  peroneii  ten- 
dons are  passed  through  a  hole  bored  in  the  os  calcis  in  opposite 
directions  and  sutured.  The  field  of  the  operation  is  very  limited 
and  it  would  appear  that  the  removal  of  the  peroneii  should  predis- 
pose to  varus  unless  constant  supervision  is  assured.     (Fig.  662.) 

Arthrodesis. — The  method  of  Jones  is  the  most  eftective  of  the 
operations  of  this  class.  It  is  divided  into  two  parts.  The  cavus 
is  first  corrected  by  the  removal  of  a  wedge-shaped  section  of  bone 
from  the  dorsum  of  the  foot  at  the  mediotarsal  joint  which  is  closed 
by  forcing  the  forefoot  into  dorsal  fexion.  Later,  an  arthrodesis 
operation  is  performed  at  the  ankle-joint  in  the  usual  manner. 

Arthrodesis  operations  have  the  disadvantage  that  they  are  not 
effective  in  inducing  anchylosis  until  the  development  of  the  bones 
is  fairly  advanced,  that  the  foot  is  fixed  at  a  right  angle  to  the  leg 
so  that  shortening  of  the  limb  cannot  be  compensated  by  an  eleva- 
tion of  the  heel,  and  finally,  because  it  enforces  disuse  of  muscles 
that  are  still  active.  These  procedures  have  not  been  described 
in  detail  because  they  have  been  in  great  degree  supplanted  by  the 
operation  of  astragalectomy  and  backward  displacement  of  the  foot, 
which  has  in  comparison  very  great  mechanical  and  practical  advan- 
tages. The  removal  of  the  astragalus  reduces  the  exaggerated 
cavus.  Backward  displacement  restores  the  prominence  of  the  heel, 
relieves  the  contraction  of  the  tissues  on  the  anterior  aspect  of  the 
joint  and  reduces  the  adverse  leverage  without  violence.  Seciuity 
is  assured  by  the  implantation  of  the  malleoli  upon  the  basic 
structure  of  the  foot  and  dorsal  flexion  is  checked  by  contact  of  the 
tibia  and  the  scaphoid.  Thus  security  is  assured  while  movement 
is  retained.  Tendon  transplantation  in  suitable  cases  supplements 
the  operation.     The  operative  details  are  as  follows: 

1  Ann.  Surg.,  January,  1915. 


840 


DEFORMITIES  OF   THE  FOOT 


Astragalectomy,  Backward  Displacement  of  the  Foot  and  Tendon 
Transplantation  (the  Author's  Operation^). — The  line  of  incision 
begins  at  a  point  abont  an  inch  above  the  extremity  of  the  external 
maheohis  midway  between  it  and  the  tendo-Achillis,  and  is  con- 
tinued downward  and  forward  about  tlu'ee-quarters  of  an  inch 
below  the  malleolus  over  the  dorsum  of  the  foot  to  the  external  sur- 
face of  the  head  of  the  astragalus. 

The  sheaths  of  the  peroneii  tendons  are  opened  and  the  tendons 
are  cut  below  the  malleolus  and  di'awn  backward.  The  bands  of 
the  external  lateral  and  interosseous  ligaments  are  divided  and  the 
head  of  the  astragalus  is  freed  from  its  attachments  to  the  tibia  and 
scaphoid.  An  elevator  is  then  inserted  between  it  and  the  os  calcis, 
and  the  foot  being  forcibly  inverted,  the  head  of  the  astragalus  is 
drawn  from  the  wound,  and,  the  attachments  on  its  inner  and 
posterior  borders  having  been  cut  or  broken,  it  is  removed.  %^ 

One,  then,  prepares  the  new  articulations.  A  thin  section  of 
bone  is  cut  from  the  adjoining  surfaces  of  the  cuboid  and  os  calcis. 


Fig.  670. — The  plaster  bandage  and  the  attitude  after  the  operation. 

On  the  inner  side  a  knife  is  passed  about  the  superior  and  internal 
surface  of  the  scaphoid  and  the  tissues  are  separated  by  an  elevator. 
The  foot  is  then  displaced  outward  and  the  malleoli  are  laid  bare  by 
dissection  from  their  ligamentous  attacliments  and  are  reshaped 
somewhat  on  their  internal  siurfaces  to  fit  the  new  articulations. 
The  peroneii  tendons,  freed  from  the  lower  extremity  of  the  fibula, 
are  passed  through  a  slit  at  the  base  of  the  tendo-Achillis,  sewn 
firmly  to  it,  and  then  drawn  forward  and  reunited  to  their  distal 
extremities  to  serve  as  ligaments. 

The  foot  is  now  displaced  backward,  the  external  malleolus 
covers  the  calcaneocuboid  articulation,  the  internal  overlaps  the 
navicular.  The  wound  is  then  closed  with  catgut  sutm-es  and  the 
foot  is  fixed  by  a  plaster  splint  in  an  attitude  of  moderate  plantar 
flexion  and  abduction. 

In  the  routine  of  hospital  practice  the  operation  is  performed 
under  the  Esmarch  bandage.     The  tendons  are  sutiu-ed  with  kan- 

1  Am.  Jour.  Aled.  Sc,  November,  1901,  and  Ann.  Surg.,  Februarj-,  190S.  Am. 
Jour.  Orthop.  Surg.,  August,  1910;  Med.  Rec,  January,  1914. 


ACQUIRED   TALIPES  CALCANEUS 


841 


garoo  tendon.  The  wound,  having  been  cleansed  with  warm  saHne 
solution,  is  closed  without  drainage.  The  foot  and  limb  are  ban- 
daged with  sterlized  sheet  wadding,  over  which  a  light  plaster  is 
applied,  holding  the  foot  in  the  attitude  described,  and  the  leg  at  a 
right  angle  to  the  thigh.  The  limb  is  afterward  suspended  between 
tapes  running  from  the  head  to  the  foot  of  the  bed.  Great  care  is 
taken  to  avoid  constriction.  To  this,  and  to  the  rest  assured  by 
the  plaster  splint,  and  to  suspension,  is  ascribed  the  very  slight 
discomfort  following  the  operation,  and  the  absence  of  complications. 
At  the  end  of  about  three  weeks  the  first  support  is  removed,  and 
the  walking  plaster  splint  is  substituted,  extending  to  the  knee,  and 
fixing  the  foot  in  the  same  attitude  of  moderate  equinovalgus,  the 


Fig.  671. — The  foot  after  the  author's  operation  for  calcaneo valgus,  showing  the 
restoration  of  symmetry.  Also  a  simple  brace  to  be  worn  temporarily  within  the 
shoe.     A  more  effective  brace  for  talipes  calcaneus  is  shown  in  Fig.  667. 


sole  being  equalized  by  the  incorporation  of  a  wedge  of  cork.  The 
patient  is  encouraged  to  walk  with  equal  steps,  and  to  bear  weight 
on  the  forward  part  of  the  foot.  At  the  end  of  from  two  to  four 
months  the  new  joint  will  have  become  stable,  and  the  fixed  support 
may  be  discarded  for  a  shoe  arranged  with  a  cork  wedge  beneath  the 
heel,  of  sufficient  thickness,  is  compensated  for  slight  equinus,  and 
if  necessary  the  outer  border  of  the  sole  is  thickened  somewhat  to 
prevent  a  tendency  to  inversion  (Fig.  674). 

Even  in  the  cases  in  which  after-treatment  has  been  neglected, 
the  nutrition  of  the  limb  and  the  appearance  of  the  foot  improve 
with  the  gain  in  functional  ability,  and  some  of  the  patients  walk 


842 


DEFORMITIES  OF   THE  FOOT 


Fig.  672. — Talipes  caicaneus  before  operation.      (See  Fig.  673.) 


Fig.  673. — Talipes  calcaneus  immediately  after  operation,  taken  through  the 
plaster.     (Compare  with  Fig.  672.) 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS    843 

so  well  as  almost  to  merit  the  term   "cure,"  as  applied  to  cases 
of  this  class. 


Fig.  674. — The  plaster  bandage  with  cork  wedge  holding  the  foot  in  equinus. 


Fig.  675. — An  .r-ray  picture  after  the  author's  operation  denionstratiufj;  the 
mechanical  prevention  of  both  lateral  and  anteroposterior  deformity.  See  Fig. 
669. 

ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS. 

In  many  cases  the  foot  deformed  as  a  result  of  paralysis  of  the 
calf  muscle  is  in  addition  turned  in  a  lateral  direction,  so  that  the 
weight  of  the  bodv  falls  to  the  inner  or  outer  side  of  its  centre  (Fig. 
676). 


844 


DEFORMITIES  OF   THE  FOOT 


Calcaneo^'algus,  in  which  the  foot  is  turned  outward  and  upward, 
so  that  the  patient  walks  on  the  inner  side  of  the  heel  or  even  on  the 
inner  ankle,  is  by  far  the  most  common.  It  is  usually  a  result  of 
more  extensive  paralysis  than  simple  calcaneus.  For  example,  all 
the  muscles  about  the  foot  may  be  disabled  except  the  peronei, 
or  in  cases  of  a  milder  t;v'pe  the  tibialis  anticus  may  be  the  only 
muscle  of  the  front  of  the  foot  that  is  paralyzed. 

Treatment. — When  the  foot  inclines  toward  calcaneovalgus  it  is 
difficult  to  hold  it  in  proper  position  by  the  ordmary  braces.  More 
efficient  supports  are  sho'^Ti  in  Figs.  667  and  677.  A  plaster  cast  of 
the  leg  with  the  foot  in  a  moderate  degree  of  plantar  flexion  is  made 
and  on  it  the  Imes  for  the  brace  are  drawn.     Occasionallv  a  metal 


Fig.  676. — Talipes  calcaneovalgus,  sho-ning  the  characteristic  distortion  and 
atrophy  of  the  foot  and  leg.  A  tjT)e  of  deformity  in  which  the  author's  operation 
is  indicated. 


sole  plate  is  used,  rising  on  the  outer  border  to  a  somewhat  less 
degree  than  on  the  inside.  The  uprights  are  riveted  to  the  foot 
plate  and  are  joined  by  a  padded  metal  band  just  below  the  tibial 
tubercle,  the  circumference  being  completed  by  a  strap.  The  shoe 
is  adjusted  to  the  brace  by  means  of  a  cork  wedge  in  the  heel. 
(See  Fig.  677.) 

Calcaneovarus  is  a  much  less  serious  affection,  since  the  foot  may 
be  more  easily  supported.  A  brace,  such  as  is  used  in  the  treatment 
of  ordinary  varus,  without  motion  at  the  ankle  or  provided  with  a 
reverse  stop,  is  ordinarily  employed.  The  author's  operation  is 
especially  indicated  for  confirmed  calcaneus  especially  of  the  valgus 
or  varus  t^-pe,  and  it  has  displaced  all  other  operative  and  mechani- 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS    845 


cal  treatment  of  confirmed  deformity  and  even  in  comparatively  early 
cases  it  may  be  indicated  as  a  conservative  treatment  in  the  sense 
of  a  preventive  of  progressive  deformity  and  disability  tendon  or 
muscle  transplantation  is  to  utilize  the  muscular  power  that  remains 
to  the  best  advantage.  Thus  a  muscle  which  only  serves  to  distort 
the  foot  may  be  transplanted  to  a  point  where  it  may  restrain 
deformity  and  improve  functional  ability  by  rebalancing  the  power. 

Tendon  Transplantation. — When  one 
or  more  of  the  muscles  are  paralyzed  the 
action  of  the  others  distorts  the  foot. 
The  object  of  tendon  transplantation  is 
to  restore  the  muscular  balance.  It  was 
first  performed  by  Nicoladoni  in  1882^ 
for  the  relief  of  paralytic  calcaneus.  The 
tendons  of  the  peroneus  longus  and  brevis 
were  divided  behind  the  external  mal- 
leolus, and  the  proximal  ends  united  to 
the  distal  extremity  of  the  divided  tendo- 
Achillis. 

The  first  operation  on  the  front  of 
the  foot  was  performed  by  Parish,^  of 
New  York,  for  the  relief  of  paralytic 
valgus,  by  sewing  the  tendon  of  the  ex- 
tensor proprius  hallucis  to  that  of  the 
paralyzed  tibialis  anticus,  without  divi- 
sion of  either  tendon.  The  field  of  the 
operation  has  since  been  extended  to 
include  almost  every  possible  combina- 
tion of  tendons  and  muscles. 

The  functions  of  the  muscles  and  their 
relative  order  of  importance  in  the  execution  of  each  movement 
have  been  described.  (Chapter  XX.)  They  are  indicated  in  the 
following  table,  modified  somewhat  from  that  of  Codivilla : 


Fig.  677.^-A    brace     for 
caneovalgus  or  varus. 


Dorsal 
flexion. 

Plantar 
flexion. 

Adduo-  :  Abduc- 
tion,         tion. 

Ever- 
sion. 

Inver- 
sion. 

Tibialis  anticus    .... 

Extensor  proprius  hallucis  . 

"        longus  digitorum' 

Peroneus  brevis  .... 

longus 
Gastrocnemius  and  soleus   . 
Tibialis  posticus 
Flexor  longus  hallucis    . 
"            "       digitorum 

1 
3 
2 

6 
3 
1 
4 
2 
5 

2 
1 
3 
4 

3 

2 

1 

3 

2 

1 

1 
6 

2 
3 
4 
5 

1  Arch.  f.  kUn.  Chir.,  1882,  iii,  xxvii,  S.  660. 

2  New  York  Med.  Jour.,  October  8,  1892. 
5  Including  peroneus  tertius, 


846  DEFORMITIES  OF   THE  FOOT 

The  relative  strength  of  a  muscle  may  be  fairly  estimated  by  its 
weight. 

Weight  of  the  MrscuLAR  Substaxce  of  the  Loxg  Muscles  of  the  Lower 
Extremity  in  the  Adult.     (Stoffel.) 

Tibialis  anticus SO  grams 

Extensor  hallucis  longus 18  " 

Extensor  digitonim  longus ^.    30  " 

Peroneus  longus 62  " 

Peroneus  bre^-is 25  " 

Tibialis  posticus 56  " 

Flexor  hallucis  longus 34  " 

Flexor  digitorum  longus 10  " 

Soleus 260  " 

Gastrocnemii 200 

Quadriceps 1650  grams 

Biceps 280 

Semimembranosus 300  "        \  760  grams 

Semitendinosus 180 

Gastrocnemius 200  " 

Soleus 260  "       ^60 

Flexor  hallucis  longus 34  " 

Flexor  digitorum  longus 10  " 

Peroneus  longus 62  " 


106 


Time  for  Operation. — The  operation  should  not  be  undertaken 
until  the  degree  of  final  paralysis  has  been  determined.  This 
stationary  stage  may  be  reached  in  a  comparatively  short  time,  but 
in  the  ordinary  cases  in  which,  for  want  of  protection,  the  part  has 
become  distorted,  it  is  practically  impossible  to  estimate  the  latent 
muscular  power  until  the  deformity  has  been  corrected,  and  until 
the  enfeebled  muscles  have  been  stimulated  by  functional  use.  In 
general,  a  period  of  two  years  at  least  should  intervene  between  the 
onset  of  the  paralysis  and  the  operation . 

The  first  essential  for  success  by  this  means  is  a  clear  under- 
standing of  the  mechanism  of  the  disabled  part  and  of  the  relative 
importance  of  its  functions.  As  regards  the  foot,  for  example, 
plantar  flexion  is  far  more  important  than  dorsal  flexion,  because 
the  inability  to  plantar  flex  implies  the  loss  of  the  principal  lifting 
and  propelling  power  of  the  body.  Dorsal  flexion  is  more  important 
than  adduction  or  abduction,  because  the  drop-foot,  so-called, 
interferes  seriously  with  locomotion.  Adduction  is  more  important 
than  abduction,  because  the  loss  of  power  to  turn  the  foot  inward 
induces  the  attitude  of  valgus,  which  is  more  disabling  and  more 
difficult  to  remedy  than  the  opposite  deformity.  To  the  im- 
portance of  these  movements  the  power  of  the  muscles  corre- 
sponds.^ 

Selection  of  Muscles. — ^In  selecting  muscles  for  transplantation 
one  attempts  usually  to  reduce  the  distorting  power  as  well  as  to 
replace  lost  fmiction.     For  example,  if  the  tibialis  anticus  were 

1  See  tables  on  page  691. 


4 


V    ' 


do      Q 


1 1 1, 


t// 


W 


Fig.  678. — The  muscles  and  tendons  Fig.  679. — The  muscles  and  tendons 

on  the  front  of  the  leg.     (Gerrish.)  on  the  back^of^the  leg.     (Gerrish.) 


848 


DEFORMITIES  OF   THE  FOOT 


paralyzed  one  would  naturally  replace  it  in  part  b}'  its  adjunct,  the 
extensor  hallucis.  This  might  complete  the  operation,  or  the  tendon 
of  the  peroneus  tertius,  the  most  direct  abductor  on  the  dorsal  sur- 
face of  the  foot,  might  be  divided  and  attached  to  the  periosteum 
on  the  inner  side  of  the  foot,  or  the  peroneus  brevis  may  be 
changed  from  a  direct  to  an  indirect  abductor  by  dividing  it  and 

sewing  it  to  the  longus  to  further  assure 
the  success  of  the  operation. 

If,  on  the  other  hand,  the  dorsal 
abductors  were  reduced  in  strength  so 
that  the  foot  turned  inward  in  dorsi- 
flexion,  the  tibialis  anticus  tendon  should 
be  split  from  its  insertion  to  the  mus- 
cular substance,  and  the  outer  half 
carried  over  the  other  tendons  and 
fastened  secm-ely  at  or  near  the  inser- 
tion of  the  peroneus  tertius  as  well  as 
to  that  tendon;  thus  the  power  of  ad- 
duction would  be  weakened  and  that  of 
abduction  increased. 

In  other  instances  the  peroneus  longus 
is  carried  across  the  front  of  the  leg 
and  is  implanted  in  the  scaphoid;  or  the 
peroneus  brevis  transplanted  in  the  same 
manner,  or  carried  behind  the  internal 
malleolus  to  serve  as  an  adductor.  It 
must  be  borne  in  mind  that  lessening 
the  deforming  power  of  the  muscles  is 
as  important  in  restoring  balance  as 
restoring  in  some  degree  that  of  the 
paralyzed  muscles.  Other  procedures 
are  combined  usually  with  tendon  trans- 
plantation to  assure  stability,  as  de- 
scribed elsewhere. 

If  the  calf  muscle  is  weak,  and  if 
the  foot  is  inclined  toward  valgus  be- 
cause of  weakness  of  the  adductor  group, 
the  two  peroneii  tendons  may  be  at- 
tached at  the  insertion  of  the  tendo- 
Achillis,  not,  of  course,  with  the  aim 
of  replacing  its  function  by  two  such 
feeble  muscles,  but  to  remove  a  distorting  force  and  to  transfer 
it  to  a  point  where  it  may  aid  in  preventing  deformity  and 
be  of  some  functional  service,  even  if  slight.  (See  Talipes  Cal- 
caneus.) 

Paralysis   of  the  tibialis  posticus  muscle  may  be  treated  by 
dividing  the  peroneus  brevis  at  or  near  its  insertion,  passing  it  be- 


FiG.  680. — Tendons  in  the 
right  sole.  (Gerrish's  Anat- 
omy.) 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS    849 

neath  the  tendo-Achillis  and  attaching  it  to  the  tendon  of  the  former. 
It  may  be  mentioned,  also,  that  sections  of  the  tendo-AchilHs  have 
been  used  to  strengthen  either  the  posterior  adductors  and  abductors 
and  even  those  of  the  anterior  group.  As  has  been  stated,  one  must 
plan  the  operation  according  to  the  function  that  is  lost  and  the 
power  that  remains  and  combine  this  procedure  if  possible  with 
other  methods  of  assuring  stability.  As  a  rule  the  most  successful 
operations  are  those  in  which  a  muscle  of  similar  function  to  that 


Fig.  681. — -The  reJative  size  and  structure  of  the  muscles  as  indicative  of  strength: 
a,  tibialis  anticus;  b,  extensor  longus  hallucis;  c.  extensor  longus  digitorum  and 
peroneus  tertius;  d,  peroneus  brevis;  e,  peroneus  longus.      (Stoffel.) 

of  the  paralyzed  one  is  transplanted.  It  is  apparent,  also,  that  it 
will  be  of  little  use  to  transfer  a  muscle  unless  its  origin  is  such  that 
it  can  work  at  a  mechanical  advantage  at  its  new  point  of  attach- 
ment. For  example,  an  anterior  adductor  may  be  changed  to  an 
abductor,  and  the  function  of  a  posterior  adductor  or  abductor  can 
be  similarly  transferred,  but  a  posterior  plantar  flexor  can  never 
be  very  efficient  as  a  dorsal  flexor;  nor  can  one  muscle  act  as  an 
extensor  and  as  a  flexor  at  the  same  time,  as  would  appear  to  be  the! 
54  ' 


850 


DEFORMITIES  OF   THE  FOOT 


belief  of  certain  contributors  to  the  literature  of  the  subject.  The 
variety  of  combinations  of  this  character  that  have  been  advocated 
is  very  large^  but  it  is  hardlj^  necessary  to  describe  them.  As  has 
been  mentioned,  one  may  always  sacrifice  a  less  important  to  a  more 
important  function,  and  as  a  weak  muscle  can  hardly  carry  out  its 
original  function  and  a  more  important  one  as  well  it  is  advisable 
in  most  instances  to  relieve  it  completely  of  the  first  in  making  the 
transfer. 


Fig.  682. — The  relative  size  and  structure  of  the  muscles  as  indicative  of  strength: 
c,  gastrocnemius;  h,  soleus;  c,  flexor  longus  digitorum;  d,  flexor  longus  hallucis;  e, 
tibialis  posticus.      (Stoffel.) 


The  Operation. — The  technic  of  the  operation  is  simple.  All 
restriction  to  normal  motion  must  be  overcome  by  preliminary 
treatment  in  order  that  the  degree  and  extent  of  functional  impair- 
ment may  be  accurately  determined.  The  incision  either  continu- 
ous or  divided  should  expose  the  muscular  substance  of  the  muscles 
and  the  point  at  which  the  transplanted  tendon  is  to  be  attached. 
By  exposing  the  parts  one  is  able  to  verify  the  diagnosis.  A 
completely  paralyzed  muscle  is  atrophied  and  of  a  dull,  reddish- 
}'ellow  color,  and  its  tendon  is  usually  of  a  yellowish- white  tinge. 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS    851 


Fig.  683. — Cross-section  of  the  leg  muscles:  a,  flexor  longus  hallucis;  b,  tibialis 
posticus;  c,  flexor  longus  digitorum;  d,  soleus;  e,  tibialis  anticus;  /,  extensor  longus 
hallucis;  g,  extensor  longus  digitorum;  h,  peroneus  longus;  i,  peroneus  brevis; 
k,  gastrocnemius.     (Stoffel.) 


Fig.  684. — Paralytic  equinovarus  before  operation.     (See  Fig.  685.) 


852 


DEFORMITIES  OF  THE  FOOT 


A  partially  paralyzed  muscle  is  atrophied,  its  tendon  is  small,  but  it 
retains  the  silvery  glisten  of  the  normal  structure.  The  tendon 
sheaths  having  been  opened,  the  tendon  is  divided  or  split  near  its 
insertion,  and  having  been  freed  from  any  restraint  that  might 
impair  its  direct  action  it  is  placed  in  apposition  to  the  tendon  of 
the  paralyzed  muscle,  whose  surface  has  been  freshened  with  the 
knife  or  better  it  is  passed  directly  through  it  and  its  extremity  is 
sewed  to  the  periosteum  of  the  neighboring  bone.  The  two  tendons 
are  then  attached  to  one  another  by  several  sutures  of  silk,  or  other 
material,  and  the  graft  is  co^^ered  by  uniting  the  tendon  sheath  or 
fatty  tissue  over  it  with  fine  catgut.     In  many  instances  the  trans- 


FiG.  685. — Paralytic  equinovarus  cured  by  operation,  sho^-ing  power  of  dorsal 
flexion  (one-half  of  the  tendon  of  the  tibialis  anticus  attached  to  the  periosteum  of 
the  outer  border  of  the  foot).  Operation  July  19,  1898.  The  direct  union  of  tendons 
to  periosteum  at  the  most  advantageous  point  has  been  urged  especially  by  Lange 
(Ueber  Periostale  Schnenverplanzung  bei  Lahmung,  Miinchen.  med.  Wchnschr., 
1900,  No.  15.) 

planted  tendon  is  attached  elsewhere  than  at  the  site  of  the  par- 
alyzed tendon  and  is  not,  therefore,  sewed  to  it,  or  it  may  be  passed 
through  the  tendon  sheath  of  the  replaced  muscle  to  lessen  the  dan- 
ger of  adhesions.^  The  skin  incision  is  closed  with  a  continuous 
catgut  suture.  The  graft  should  be  applied  under  a  certain  tension, 
all  the  slack  being  dra^Aii  in,  as  it  were,  so  that  the  foot  may  be  held 
if  possible  in  the  normal  attitude.  This  attitude  may  be  further 
assured  by  implantation  of  tendon  of  the  paralyzed  muscle  in  the 
bone  or  by  arthrodesis  operations.  A  plaster  bandage  is  then 
applied  in  the  overcorrected  position,  and  in  this  attitude  the  foot 


iBiesalski,  Veihand.  D.  Orth.,  Gesells.,  1915. 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS    853 

should  be  used  for  many  months  until  a  change  m  its  shape  and 
structure  may  further  assure  stability. 

Modifications  of  the  Operation. — As  has  been  stated  since  its  intro- 
duction, the  operation  of  tendon  transplantation  has  been  modified 
in  several  particulars.  It  has  been  demonstrated  by  experience 
that  there  is  a  strong  tendency  toward  relapse  to  the  original  deform- 
ity, because  of  weakness  of  the  transposed  muscle,  the  mechanical 
disadvantage  at  which  it  acts  and  in  some  degree  because  of  the 
insecurity  of  its  attachment. 


M 


Fig.  686. — The  peroneus 
longus  transplanted  to  the 
front  of  the  Hmb  to  serve 
as  a  dorsal  flexor. 


Fig.  687. — The  peroneus 
brevis  carried  behind  the 
leg  and  the  internal  mal- 
leolus to  the  tendon  of  the 
tibialis  posticus  to  serve  as 
an  adductor. 


Fig.  688.  —  The 
tendon  of  the  tibialis 
posticus  displaced 
forward  to  serve  as 
a  dorsal  flexor. 


Lange  was  the  first  to  urge  that  the  tendon  of  the  living  muscle 
should  not  be  attached  to  that  of  the  paralyzed  one,  but  should  be 
fixed  directly  to  the  periosteum  or  bone  at  the  point  of  greatest 
mechanical  efficiency.  This  procedure  has  now  been  generally 
adopted  or  at  least  the  tendinous  attachment  has  become  supple- 
mental to  the  periosteal.  If  the  tendon  is  not  long  enough  for  this 
purpose  it  may  be  lengthened  by  means  of  a  silk  cord  quilted  into 
its  substance.  By  this  means  the  scope  of  the  operation  has  been 
greatly  extended  both  in  the  applicability  to  the  foot  and  to  other 


854 


DEFORMITIES  OF  THE  FOOT 


parts  of  the  body.  Lange  uses  strong  silk  ligatures  previously 
boiled  in  a  solution  of  corrosive  sublimate  (1  to  1000).  These  are 
dried  and  are  preserved  in  paraffin  which  lessens  the  danger  of 
adhesion  with  the  surrounding  tissues.  The  muscle  to  be  trans- 
ferred, for  example,  the  peroneus  longus  or  brevis,  to  replace  the 
tibialis  anticus,  is  exposed  by  a  long  incision  over  the  fibula.  It  is 
separated  ui  the  greater  part  of  its  area  from  its  attachments,  its 
extremity  is  passed  across  the  front  of  the  leg  beneath  the  skin  and 
is  drawn  through  an  incision  in  the  line  of  the  tibialis  anticus.  To 
it  the  silk  cord  is  attached  by  quilting  it  through  its  substance.     A 


Fig.  689. — Transplan- 
tation of  the  tibialis  anti- 
cus to  the  outer  border  of 
the  foot.  In  some  in- 
stances the  tendon  is  split 
to  the  muscular  substance 
and  the  outer  half  trans- 
planted. 


Fig.     690. 


Extensor 


proprius  hallucis  trans- 
planted to  the  scaphoid 
region. 


Fig.  691.— Thb  tendon 
of  the  peroneus  brevis 
displaced  forward  to  serve 
as  a  dorsal  flexor. 


free  channel  is  then  made  directly  beneath  the  skin  to  an  incision 
over  the  scaphoid.  Through  this  the  silk  tendon  is  drawn  and  is 
firmly  attached  to  the  periosteum  of  the  navicular.  The  foot  is 
then  fixed  in  the  inverted  position  by  a  plaster  support.  In  most 
instances,  however,  if  the  tendon  to  be  transplanted  is  divided  at 
its  insertion  the  use  of  silk  prolongation  may  be  avoided. 

Tendon  Transplantation  in  Combination  with  Other  Procedures. — As 
the  object  of  operative  treatment  is  to  prevent  deformity  and  to 
increase  the  stability  of  the  foot,  tendon  transplantation  may  be  of 
greater   service  when   combined   with   other   operations.     One   of 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS    855 

these  lias  been  mentioned  in  the  treatment  of  tahpes  calcaneous. 
(See  page  838.)  For  valgus  deformity  arthrodesis  of  the  astraga- 
lonavicular  articulation  is  a  valuable  adjunct  of  tendon  trans- 
plantation. An  incision  about  three  inches  in  length,  long  enough 
to  expose  the  muscular  substance  of  the  extensor  longus  hallucis 
and  the  astragalonavicular  articulation  is  made.  This  joint  is  then 
opened  and  the  cartilage  is  thoroughly  removed  from  the  adjoining 
bones.  The  tibialis  anticus  is  implanted  in  the  lower  end  of  the 
tibia  and  the  tendon  of  the  proprius  hallucis  is  divided  and  is  sewed 
to  it  and  to  the  inner  border  of  the  navicular  at  such  tension  as  to 
hold  the  foot  in  inversion.     The  ligament  covering  the  denuded 


Fig.  692. — Talipes  equinovalgus  after  treatment  by  tendon  transplantation. 
The  tendon  of  the  peroneus  tertius  was  attached  to  the  overlapped  and  shortened 
tendon  of  the  tibialis  anticus.  All  the  tendons  on  the  front  of  the  foot  were  then 
united,  so  that  all  might  serve  as  dorsal  flexors. 

bones  is  then  shortened  and  sewed  with  silk  or  kangaroo  sutures, 
the  wound  is  closed  and  the  foot  is  fixed  in  extreme  inversion  and 
slight  dorsal  flexion  by  a  plaster  bandage.  A  similar  procedure  is 
employed  if  the  deformity  is  of  the  varus  type,  in  which  half  the 
tibialis  anticus  muscle  elongated  if  necessary  by  means  of  silk  cord 
attached  to  the  outer  border  of  the  foot.  A  thin  wedge  of  bone, 
including  the  calcaneocuboid  and  the  outer  half  of  the  astragalo- 
navicular articulation,  is  removed  from  the  dorsal  aspect  of  the 
foot.  Forced  abduction  closes  the  opening  and  continued  contact 
is  assured  by  several  heavy  silk  sutures.  In  cases  in  which  the 
lateral  deformity  is  extreme,  arthrodesis  at  the  subastragaloid  in 


856  DEFORMITIES  OF  TEE  FOOT     , 

addition  to  that  at  the  astragaloscaphoid  articulation,  as  suggested 
by  Codavilla  and  Davis/  is  advisable.  The  posterior  articulation 
is  reached  by  a  longitudinal  incision  below  the  external  malleolus, 
the  anterior  below  and  in  front  of  the  internal  malleolus.  The 
adjoining  surfaces  are  thoroughly  "dug  out"  and  all  bone  chips  are 
left. 

The  foot  should  be  retained  for  seA^eral  months  in  the  overcor- 
rected  position  by  a  plaster  bandage,  on  which  the  patient  walks 
about  until  the  parts  have  thoroughly  conformed  to  the  new  position, 
the  aim  being  to  supplement  muscular  weakness  by  a  fixed  attitude  or 
slight  deformity  of  a  character  opposed  to  that  for  which  the  opera- 
tion was  performed.  In  many  instances  further  support  is  unnec- 
essary, but  a  brace  should  be  used  if  there  is  a  tendency  toward 
deformity.  Massage,  passive  and  active  exercises  in  the  direction 
opposed  to  deformity  are  of  great  importance  in  after-treatment. 

The  prognosis  depends  upon  the  degree  of  permanent  paralysis 
and  its  distribution.  It  is,  of  course,  evident  that  tendon  trans- 
plantation is  essentially  a  palliative  rather  than  a  curative  operation. 
In  selected  cases  in  which  the  attachment  is  directly  to  the  bone, 
and  especially  when  lateral  motion  is  checked  by  arthrodesis,  the 
results  are  very  satisfactory.  The  improvement  in  functional 
ability  is  immediately  shown  in  the  nutrition  of  the  limb.  In  some 
cases  of  this  class  the  transferred  muscle  apparently  undergoes  an 
adaptive  hypertrophy  in  the  new  function  but  in  all  cases  deformity 
must  be  prevented  by  manipulative  exercises  and  by  balancing  the 
shoe. 

Silk  Ligaments. — As  has  been  mentioned  elsewhere  silk  ligaments 
were  originally  designed  as  permanent  internal  stays  to  support  the 
foot  in  the  desired  position  on  the  assumption  that  they  might  be 
transformed  to  unyielding  fibrous  tissue.  They  are  of  some  service 
in  connection  with  braces  as  an  additional  means  of  security  or  in 
combination  with  artlu-odesis  or  tendon  transplantation,  but  it  is 
now  generally  recognized  that  their  usefulness  is  limited.  Lovett^ 
describes  the  operation  as  follows  (Fig.  658) : 

"In  the  technic  one  or  two  matters  are  of  much  importance.  The 
crest  of  the  tibia  above  the  ankle  is  exposed,  periosteum  incised  and 
turned  back,  and  a  hole  drilled  in  the  bone.  One  of  the  bones  in  the 
tarsus  at  the  inner  or  outer  side  of  the  foot,  or  both,  as  the  indication 
for  support  determines,  is  drilled  in  the  same  wa\",  and  one  or  two 
strands  of  heavy  silk  are  passed  through  the  tibial  hole  under  the 
annular  ligament,  tlu'ough  the  tarsal  hole,  and  tied.  The  knot 
must  come  in  the  upper  wound,  as  otherwise  it  is  likely  to  chafe 
through  from  pressure  of  the  boot.  At  least  three  months'  support 
is  necessary,  and  probably  more." 

1  Davis:  Am.  Jour.  Orthop.  Surg.,  November,  1916. 

2  Jour.  Am.  Med.  Assn.,  Jamiary  24,  1914. 


ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVARUS     857 

Tendon  Implantation  or  Tenodesis. — Although  operation  for  the 
conversion  of  the  tendons  of  paralyzed  muscles  into  tendons  has  in 
past  years  been  performed  by  several  surgeons,  Gallie  has  perfected 
and  popularized  the  operation  which  has  in  great  degree  sup- 
planted the  use  of  silk  ligaments.  The  operation  in  brief  consists 
of  separating  the  periosteum  from  the  bone  and  gouging  a  trough  of 
sufficient  depth  to  contain  the  tendon  which  is  placed  within  it  at 
sufficient  tension  to  hold  the  foot  in  proper  position,  and  fixed  by 
kangaroo-tendon  sutures  passed  from  the  periosteum  and  cartilagi- 
nous covering  of  the  bone  through  the  tendon  which  is  thus 
embedded  in  the  bone.  In  the  earlier  operations  the  tendon  was  not 
separated  from  the  muscular  substances  but  such  division  does  not 
affect  the  result.  The  tendon  sheath  must  be  thoroughly  removed, 
the  tendon  bruised,  and  it  is  well  to  leave  the  bone  chips  in  the 
groove  in  order  to  assure  fixation.  The  operation  is  most  useful 
as  an  adjunct  to  tendon  transplantation  in  the  treatment  of  lateral 
distortion.  The  tendon  of  the  tibialis  anticus  implanted  on  the 
internal  aspect  of  the  tibia  for  valgus;  the  two  peroneii  into  the 
fibula  for  varus,  as  shown  in  the  illustrations  (Figs.  660  and  661 ) . 

Arthrodesis. — The  removal  of  the  cartilaginous  surfaces  of- 
articulating  bones  to  induce  anchylosis  for  the  relief  of  paralytic 
deformities  of  the  foot  was  first  performed  by  Albert,  of  Vienna, 
in  1878.  As  applied  to  the  foot,  it  is  of  special  service  as  the  medio- 
tarsal  and  subastragaloid  joints  in  connection  with  tendon  trans- 
plantation to  prevent  lateral  deformity.  It  is  of  little  value  in  the 
younger  class  of  patients,  as  the  bones  are  not  sufficiently  developed 
to  assure  adhesion.    Eight  years  has  been  suggested  as  the  age  limit. 

Formerly  it  was  employed  to  fix  the  ankle-joint  but  far  less  often 
at  the  present  time.  The  operation  consists  in  opening  the  joint 
and  removing  the  cartilage  from  the  apposed  surfaces  of  the  bones, 
then  fixing  them  in  contact  by  nails,  bone  pegs  or  sutures  or  by  a 
plaster  bandage  until  union  has  taken  place.  The  usual  incision  is 
about  two  inches  in  length  over  the  front  of  the  ankle-joint.  The 
foot  is  then  plantar  flexed  and  the  cartilage  is  thoroughly  removed 
from  the  articulating  surfaces  with  a  thin  chisel  or  knife.  The  lateral 
incision  as  used  for  the  removal  of  the  astragalus  with  inward  dis- 
placement of  the  foot  permits  a  more  thorough  inspection  of  the  joint 
and  in  many  instances  it  is  to  be  preferred.  As  the  removal  of  the 
cartilage  at  the  ankle-joint  increases  its  capacity  and  thus  prevents 
accurate  apposition,  Farrabeuf  and  Goldthwait  divide  the  fibula 
above  the  articulation  so  that  it  may  be  forced  against  the  astragalus. 
If  lateral  deformity  is  present  the  subastragaloid  joints  are  destroyed, 
and  by  prolonging  the  lateral  incision  over  the  dorsum  of  the  foot 
the  mediotarsal  may  be  reached  and  by  an  incision  below  the  external 
malleolus  that  between  the  astragalus  and  os  calcis.  As  a  rule  in 
cases  of  complete  paralysis  of  the  anterior  group  simple  anchylosis 
at  the  ankle-joint  is  not  sufficient  to  prevent  the  toe-drop,  and  it 


858  DEFORMITIES  OF  THE  FOOT 

is  well  to  destroy  the  mediotarsal  joint  also.  A  convenient  method 
is  to  remove  the  cartilaginous  surface  of  the  astragalonavicular  and 
calcaneocuboid  articulations,  together  with  a  thin  wedge  of  bone, 
base  uppermost.  In  some  instances  the  tendons  of  the  paralyzed 
muscles  are  implanted  to  aid  in  retaining  the  foot  in  the  improved 
position.  This,  however,  is  of  minor  importance.  The  operation 
should  be  performed  under  the  Esmarch  bandage,  and  the  limb 
should  be  elevated  for  a  time  to  prevent  the  subsequent  bleeding 
from  the  bones  (Fig.  657). 

The  improvement  in  the  gait,  obtained  by  the  rectification  of 
deformity,  and  by  fixation  of  the  foot,  after  arthrodesis,  is  often 
very  marked.  In  many  instances,  though  bony  anchylosis  is  not 
attained,  the  limitation  of  movement  is  sufficient  to  restrain 
deformity  and  to  permit  the  patient  to  discard  apparatus,  although 
discomfort  on  overuse  or  strain  is  often  experienced.  Anchylosis 
has  the  disadvantage  of  hampering  the  function  of  all  the  active 
muscles,  and  fixation  at  a  right  angle  prevents  the  adjustment  of  an 
inoffensive  shoe  to  compensate  for  a  shortened  leg. 


CHAPTER  XXIV. 
MILITARY  ORTHOPEDICS. 

The  chief  distinction  of  orthopedic  treatment  is  that  it  is  con- 
ducted from  the  functional  stand-point,  in  view,  therefore,  of  the 
final,  rather  than  of  the  immediate  result. 

Military  orthopedics,  it  may  be  assumed,  is  chiefly  concerned  with 
the  disabilities  of  the  locomotive  apparatus,  particularly  with  the 
prevention  and  correction  of  deformities  of  the  lower  extremities, 
deformity  being  defined  as  any  persistent  attitude  that  embarrasses 
function. 

The  more  important  primary  causes  of  locomotor  disability  are 
fractures,  often  compound,  suppuration  and  scar  contraction,  joint 
disease  or  injury,  and  paralysis. 

The  secondary  causes  of  deformity  are  the  force  of  gravity;  mus- 
cular contraction;  and  the  adaptation  of  the  tissues  to  habitual 
attitudes. 

The  influence  of  the  force  of  gravity  is  best  illustrated  by  toe-drop 
and  the  resulting  equinus,  a  very  common  effect  of  disease  or 
injury,  or  even  of  simple  weakness. 

Muscular  spasm  always  accompanies  injury  or  disease  of  the 
bones  or  joints.  The  muscles  are  safeguards  of  the  joints  and  in 
their  attempts  to  restrain  painful  movements  they  increase  the  dis- 
comfort and  induce  deformity. 

Flexion  is  the  attitude  of  relaxation,  consequently,  that  which  is 
always  assumed  in  adaptation  to  disease  or  weakness,  an  attitude  to 
which  the  tissues  rapidly  accommodate  themselves  if  it  is  allowed  to 
persist.    Thus  fixed  flexion  is  the  most  common  of  all  distortions. 

The  secondary  causes  of  deformity  vary  in  relative  importance 
with  the  character  of  the  injury,  but  they  are  so  constant  that  in 
most  cases  deformity  can  be  prevented  only  by  supporting  the  limb 
in  the  position  best  suited  for  the  weight-bearing  function  and  about 
which  motion,  if  limited,  will  be  of  the  greatest  service. 

At  the  hip-joint  the  attitude  of  selection  is  complete  extension 
and  about  15  degrees  of  abduction;  the  most  common  and  disabling 
deformity  being  flexion  and  adduction  of  the  limb. 

Of  the  two,  adduction  is  the  more  important,  since  in  this  attitude 
the  support  is  insecure,  while  the  compensatory  elevation  of  the 
pelvis  causes  apparent  shortening  of  the  limb,  as  explained  in  the 
chapter  on  Hip  Disease. 

Flexion  is  an  almost  inevitable  result  of  disease  or  injury  of  the 
hip-joint  that  limits  motion.    In  moderate  degree,  flexion  does  not 


860  MILITARY  ORTHOPEDICS 

interfere  with  function,  but  if  extreme,  it  is  a  direct  cause  of  dis- 
ability and  induces  a  compensatory  lordosis  that  usually  causes 
discomfort  in  the  back  when  the  upright  posture  is  assumed. 

At  the  knee  the  proper  attitude  is  complete  extension.  Flexion, 
unless  prevented,  is  inevitable  and  leads  to  subluxation  and  outward 
rotation  of  the  tibia,  deformities  which  when  once  established  are 
difficult  to  correct. 

At  the  ankle  the  foot  should  be  supported  at  a  right  angle  to  the 
leg  and  very  slightly  inverted,  so  that  weight  may  be  borne  without 
strain  upon  the  joints.  Persistent  discomfort,  so  common  after  an 
injury  in  this  neighborhood,  is  usually  explained  by  abduction  inwhich 
the  weight  is  thrown  upon  the  inner  side  of  the  foot,  a  strain  that 
is  aggravated  by  the  limitation  of  dorsal  flexion  that  is  often  present. 

Deformities  of  the  upper  limbs  are  of  less  direct  importance 
because  they  do  not  support  weight.  At  the  shoulder,  as  at  the 
hip,  the  attitude  should  be  one  of  moderate  abduction.  At  the  elbow, 
right  angular  flexion,  with  the  forearm  supinated.  The  hand 
should  be  dorsiflexed  at  the  wrist  to  permit  the  grasp  of  the  fingers. 

In  a  treatment  directed  to  the  prevention  of  deformity,  the  rela- 
tive importance  of  the  factors  that  have  been  mentioned  should 
be  considered  in  each  instance.  The  postures  characteristic  of  par- 
alysis or  weakness,  induced  in  great  part  by  gravity,  may  be  easily 
prevented  by  supporting  the  part  in  the  attitude  of  selection  and 
by  passive  movements  in  the  directions  opposed  to  the  deformity, 
as  described  in  the  chapter  on  Anterior  Poliomyelitis. 

Muscular  contraction  as  an  agent  of  deformity,  is  most  potent 
as  an  accompaniment  of  fracture  or  joint  disease.  In  the  former 
instance  it  may  be  checked  by  adjustment  of  the  fragments  and 
effective  splinting.  If,  however,  the  fracture  is  of  such  a  character 
that  end-to-end  resistance  of  the  bones  cannot  be  assured,  splinting 
should  be  combined  with  traction.  Traction,  if  sufficient  and 
constant,  will  prevent  displacement  and  by  tension  on  the  muscles 
make  them  serve  as  an  internal  splint  to  adjust  and  fix  the  fragments. 

Muscular  spasm  is  most  intense  in  acute  affections  of  the  joints, 
whether  primary  or  secondary  to  injury,  and  in  such  cases  flexion 
deformity  is  inevitable  unless  it  is  prevented.  In  many  instances 
splinting  is  not  sufficient  and  traction  must  be  applied  with  the  aim 
of  separating  the  sensitive  surfaces  from  one  another.  If  pain  is  not 
checked  by  the  rest  assured  by  traction  and  splinting,  it  usually 
implies  local  tension,  which  should  be  relieved  by  aspiration,  or  by 
incision,  and  the  same  is  true  of  disease  of  the  bones  or  other  tissues. 

If  the  injured  part  is  very  sensitive  to  jars  or  movements  of  the 
body,  the  limb  may  be  suspended  with  advantage  by  some  form  of 
splint  of  the  Hogden  type  that  permits  both  support  and  traction. 
Suspension  splints  may  be  improvised  from  thick  wire,  and  are  very 
serviceable  in  the  treatment  of  both  the  upper  and  low*er  extremities 
when  wounds  require  frequent  dressing.     The  Thomas  knee  brace, 


MILITARY  ORTHOPEDICS 


861 


arranged  for  traction,  is  especially  useful  in  treatment  of  fracture 
of  the  thigh  and  for  injuries  of  the  knee,  and  the  Thomas  hip  splint, 
provided  with  a  foot  rest  when  support  of  the  entire  limb  is  required. 
Plaster  splints,  strengthened  with  steel,  if  skilfully  adjusted,  may 
often  serve  their  purpose  as  well  as  prepared  apparatus. 

It  must  be  borne  in  mind  that  shortening  of  the  limb  from  the 
functional  stand-point  is  of  small  importance  compared  to  dis- 
tortions that  cause  insecurity  of  support,  or  that  interfere  with  the 


Fig.  693. — A  simple  brace  to  support 
the  hand  in  dorsal  flexion.  (Jones.) 


Fig.  694. — The  support  applied. 


Fig.  695. — A  brace  to  support  the  Fig.  696.' — The  brace  applied,  showing  the 
forearm  and  to  apply  traction  on  the  traction  bandage, 

upper  arm.     (Jones.) 

movements  of  the  joints.  When,  for  example,  a  joint  is  supported 
by  two  bones,  as  at  the  ankle  and  wrist,  the  removal  of  a  part  of  one 
will  almost  inevitably  lead  to  distortion  unless  compensation  is 
made  for  the  inequality. 

In  the  treatment  of  disability  due  to  deformity  one  attempts  to 
restore  the  selected  attitudes  at  the  various  joints  that  have  been 
described  as  most  useful  when  function  is  impaired,  and  the  method 
of  accomplishment  must  be  adapted  to  the  condition.  In  many 
instances  forcible  manipulation  under  anesthesia,  combined  with 
division  of  the  more  resistant  parts,  will  accomplish  its  purpose 

1  These  cuts  illustrating  simple  and  easily  constructed  apparatus  have  been  taken 
from  Injuries  to  the  Joints,  by  Robert  Jones,  1917. 


862 


MILITARY  ORTHOPEDICS 


in  one  or  more  attempts.  This  method  has  the  advantage  that  the 
correction  involves  all  the  contracted  parts. 

If,  however,  the  deformity  is  of  long  standing,  preliminary  cutting 
of  the  contracted  tissues  is  advisable  in  order  to  avoid  injury  to 
the  atrophied  bones. 

In  the  cases  of  deformity  following  fracture  it  is  often  advisable 
to  correct  it  by  a  simple  osteotomy,  rather  than  to  separate  firmly 
united  fragments  in  the  attempt  to  assure  absolute  symmetry. 


Fig.  698. — The  frame  applied. 


Fig.  697. — The  Thomas- Jones  abduction  hip 
splint  frame,  showing  the  traction  straps  and 
bandages  and  the  thick  cushion  on  which  the 
patient  lies.  Fracture  of  the  neck  of  the  femur 
may  be  treated  by  this  apparatus. 


In  fractures  involving  joints  it  is  sometimes  possible  to  increase  the 
range  of  movement  by  removing  projecting  fragments  or  callus  forma- 
tions about  the  margins,  and  such  operations  are  especially  indicated 
when  the  limitation  prevents  the  attitude  of  greatest  usefulness. 

When  the  position  of  election  has  been  attained  one  attempts  to 
increase  the  range  of  motion  by  massage,  passive  movements  and 
functional  exercise. 

Operations  on  ankylosed  joints  for  the  purpose  of  restoring  motion 
are  more  often  indicated  in  the  upper  extremity  where  security  is 
of  less  functional  importance  than  mobility,  than  in  the  lower  limb 
where  conditions  are  reversed.  The  treatment  must  be  decided, 
therefore,  by  the  conditions  and  requirements  of  the  individual  case. 


MILITARY  ORTHOPEDICS 


863 


Fig.  699. — Diagram  showing  Thomas's  knee-splint  as  used  for  fracture  of  the 
femur  below  the  small  trochanter,  about  the  knee  and  upper  part  of  the  leg.  Arthritis 
of  knee,  compound  fracture  of  patella,  etc.  The  gutter-splint  behind  is  slung  from 
the  side-bars.  If  necessary  to  get  free  access  to  a  wound  about  the  knee,  leg  and 
thigh  would  be  separately  slung.  To  avoid  confusion,  only  the  lower  end  of  the 
extension  plaster  is  shown;  also  all  bandages  and  padding  are  omitted.  The  anterior 
splint  is  such«s  would  be  used  for  fracture  of  the  shaft  of  the  femur.  The  blocks 
supporting  the  end  of  the  splint  keep  the  heel  off  the  bed  and  protects  the  heel. 


Fig.  700.— The  Thomas        Fig.  701.— Caliper      Fig.  702.— The  shoe  and  strap. 
caliper  knee  brace.        leg  brace  for  lateral 
deformity  of  foot. 


Fig.  703.— Caliper  foot  brace  for 
lateral  deformity  applied. 


Fig.  704. — ^Rectangular  foot  splint. 


864  MILITARY  ORTHOPEDICS 

There  is  no  essential  distinction  between  military  and  civil 
orthopedics,  except  that  the  former  deals  with  a  restricted  class  of 
cases  and  that  the  methods  employed  must  be  adapted  to  adverse 
conditions. 

What  has  been  termed  secondary  deformity  is  far  more  often  due 
to  inadvertence  or  neglect  than  to  any  particular  difficulty  in  apply- 
ing effective  prevention.  For  this  reason  attention  has  been  called 
to  certain  orthopedic  principles  that  have  been  explained  at  length 
in  the  preceding  chapters. 

The  character  of  orthopedic  or  reconstruction  treatment  as  it  is 
practically  applied  is  very  well  presented  in  the  following  abstracts 
from  an  address  by  Dr.  W.  E.  Gallic,  of  Toronto: 

HOW  CANADA  IS  CARING  FOR  HER  CRIPPLED  SOLDIERS.^ 

The  types  of  patients  admitted  to  reconstruction  hospitals  are 
definitely  described  in  order.    They  are  as  follows: 

(a)  Derangements  and  disabilities  of  joints,  simple  and  grave, 
including  ankylosis. 

(6)  Deformities  and  disabilities  of  feet,  such  as  hallux  rigidus, 
hallux  valgus,  hammer-toes,  metatarsalgia,  painful  heels,  fiat  and 
claw  feet. 

(c)  Malunited  and  ununited  fractures. 

{d)  Injuries  to  ligaments,  muscles  and  tendons. 

{e)  Cases  requiring  tendon  transplantation  or  other  measures  for 
irreparable  destruction  of  nerves. 

(/)  Nerve  injuries  complicated  by  fractures  or  stiffness  of  joints. 

{g)  Certain  complicated  gunshot  injuries  to  joints. 

(Ji)  Cases  requiring  surgical  appliances. 

Examining  the  orthopedic  classification  more  closely  it  will  be 
seen  that  Group  A,  "the  derangements  and  disabilities  of  joints, 
etc.,"  includes  not  only  the  results  of  gunshot  wounds  and  other 
violent  injuries  to  joints,  but  also  the  various  inflammatory  con- 
ditions which  we  are  more  accustomed  to  see  in  civil  life.  It  involves 
the  whole  operative  field  of  excisions  and  arthroplasties  and  other 
methods  of  stabilizing  and  mobilizing  the  damaged  joints. 

Group  B,  "the  pathological  conditions  of  the  feet,"  is  familiar 
to  us  all,  and  calls  for  no  comment.  The  severity  of  the  cases  of 
flat  feet,  however,  which  retm-n  as  unfit  for  fm'ther  service,  leaves 
no  doubt  as  to  the  wisdom  of  the  recent  orders  which  designate  as 
medically  unfit  the  would-be  recruit  who  had  any  tendency  to  weak- 
ness of  the  feet. 

Group  C,  "malunited  and  ununited  fractures,"  a  group  which  has 
hitherto  been  considered  on  the  borderland  between  orthopedic  and 
general  surgery,  affords  ample  scope  for  all  our  mechanical  skill, 

1  Am.  Jour.  Ovth.  Surgery,  July,  1917. 


RECONSTRUCTIVE  TREATMENT  865 

while  providing  a  host  of  cases  which  are  at  once  the  most  interesting 
and  the  most  satisfactory  from  the  stand-point  of  the  results  to  be 
hoped  for.  Our  patients  include  ununited  fractures  of  the  jaw, 
humerus,  forearm  bones,  femur,  tibia  and  patella,  and  they  afford 
ample  opportunity  for  our  recently  acquired  knowledge  of  the  trans- 
plantation of  bone.  Up  to  the  present  the  most  interesting  work 
has  been  provided  by  the  gunshot  wounds  of  the  mandible,  in  which 
gaps  of  from  one  to  four  inches  have  to  be  filled.  The  results,  both 
from  the  stand-point  of  the  restoration  of  function  and  the  improve- 
ment in  facial  appearance,  have  been  most  gratifying.  The  mal- 
united  fractures  invariably  present  difficult  surgical  problems.  The 
constant  presence  of  infection  in  gunshot  wounds  of  the  bones,  and 
the  difficulty  in  applying  the  ordinary  principles  of  treatment  in  the 
early  months  following  the  injury,  has  led  to  the  most  lamentable 
results.  Overlaps  of  three  and  four  inches,  extreme  angulations 
and  unsightly  distortions,  usually  complicated  by  paralysis  from 
injuries  to  nerves  and  contractures  from  neglect  in  the  treatment, 
are,  unfortunately,  of  frequent  occurrence.  Each  case  demands  the 
acute  judgment  of  the  surgeon,  and  when  operation  is  decided  upon, 
calls  for  the  best  skill  that  he  can  give.  Experience  has  taught  us 
that  it  is  unwise  to  undertake  operative  work  on  the  bones  until 
many  months  have  elapsed  after  the  last  signs  of  infection  have 
disappeared.  Unsuspected  infection  lurks  about  the  ends  of 
damaged  bones  for  a  long  time  after  the  wound  has  healed,  and 
extensive  operative  work  is  very  apt  to  end  diastrously  from  the 
lighting  up  of  old  infection.  Several  most  unfortunate  results  have 
been  returned  to  us  which  have  arisen  from  the  unwise  haste  of  the 
surgeon  to  secure  a  complete  cure.  In  one  case  of  my  own  I  had 
waited  five  months  after  the  complete  healing  of  a  wound  of  the  bones 
of  the  forearm,  and  was  just  about  to  send  the  patient  into  the 
hospital  for  a  bone  transplantation,  when  a  small  red  spot  appeared 
in  the  wound,  and  a  splinter  of  dead  bone  worked  its  way  out  in 
the  course  of  a  day  or  two.  Six  months  appears  to  be  the  minimum 
time  which  should  elapse  between  the  healing  of  the  primary  wound 
and  the  reparative  bone  operation. 

Group  D,  "Injuries  to  ligaments,  muscles  and  tendons,"  provides 
a  class  of  patients  for  whom  much  can  be  done  by  massage,  stretching 
and  exercise.  In  order  that  real  benefit  may  be  obtained  from  these 
therapeutic  measures,  however,  it  is  imperative  that  proper  super- 
vision of  the  treatments  be  maintained.  Until  recently  we  have 
been  very  lax  in  this  department,  owing  to  lack  of  skilled  assistance, 
but  recently  the  matter  of  mechanotherapeutics  has  been  taken  up 
by  the  psychological  department  of  the  University  of  Toronto  with 
very  satisfactory  results.  The  futility  of  providing  standardized 
apparatus  for  this  conglomerate  mass  of  cases  was  early  recognized. 
When  our  convalescent  hospitals  were  first  established  they  were 
immediately  equipped  with  various  pieces  of  Zander  apparatus, 
55 


SG6  MILITARY  ORTHOPEDICS 

exercises,  etc.,  which  made  a  fine  show  on  patriotic  occasions,  but 
which  never  seemed  exactly  to  fit  the  various  cases  which  presented 
themselves  for  treatment.  It  is  a  well-proven  rule  that  medical 
apparatus  almost  invariably  works  best  in  the  hands  of  the  inventor 
or  his  associates,  and  this  is  being  demonstrated  once  more  in  the 
new  department  of  mechanotherapeutics  in  Toronto.  It  is  curious 
that  the  department  of  psychology  should  ha^'e  taken  the  matter 
up,  but  it  arose  from  the  interest  that  this  department  developed 
in  the  study  and  treatment  of  various  gunshot  wounds  of  the  brain 
and  in  the  numerous  psychoneuroses  which  are  being  returned  to  our 
hospitals.  With  the  assistance  of  an  expert  mechanic,  various 
pieces  of  cheap  but  ingenious  apparatus  began  to  be  evolved,  suited 
to  each  individual  case.  Until  now  the  interest  of  the  authorities 
and  the  public  has  been  attracted,  and  the  department  has  under- 
taken, with  the  assistance  of  medical  advice,  to  take  charge  of  the 
mechanical  treatment  of  all  forms  of  crippling  conditions.  The 
idea  of  devising  and  making  up  cheap  apparatus  for  each  individual 
case,  and  of  providing  individual  instruction  for  each  patient 
appears  to  be  the  secret  of  the  success,  for  which  much  credit  is  due 
to  the  staff  of  the  department  of  psychology. 

Group  E,  "cases  requiring  tendon  transplantation  or  other 
measures,  for  irreparable  destruction  of  nerves."  This  group  gives 
opportunity  for  such  operations  as  arthrodesis  and  tendon  fixation, 
as  well  as  transplantation.  In  several  cases  of  permanent  peroneal 
paralysis,  fixation  of  the  tendons  of  the  peronei  has  been  very  satis- 
factory. 

Group  F,  "nerve  injuries  complicated  by  fractures  or  stiffness  of 
joints."  This  comprises  practically  all  the  cases  of  nerve  injury 
which  are  returned  to  us,  as  nearly  every  case  has  developed  contrac- 
tures of  some  sort  by  the  time  he  reaches  the  hospitals  at  home.  One 
reason  for  this  can  be  discovered  in  the  mania  which  spread  through 
the  base  hospitals  in  England  for  overdoing  the  treatment  recom- 
mended years  ago  by  Jones — the  placing  of  paralyzed  muscles  at 
rest  in  a  position  of  relaxation.  Dozens  of  cases  of  musculospinal 
paralysis  have  come  home,  the  nerve  having  been  carefully  sutured, 
wearing  the  so-called  "  cocked-up  splint,"  which  held  the  fingers  and 
wrist  in  a  position  of  hyperextension.  In^'ariably  these  patients  had 
developed  contracture  of  the  capsules  of  the  metatarsophalangeal 
joints  posteriorly,  so  that  not  the  slightest  motion  in  the  direction  of 
of  flexion  could  be  obtained.  The  result  of  treatment,  therefore, 
was  the  destruction  of  the  function  of  the  flexors  by  the  contractures, 
to  add  to  the  destruction  of  the  extensors  already  produced  by  the 
nerve  injury.  Fortunately  the  "cocked-up  splint"  appears  to  have 
been  abandoned,  as  much  fewer  of  these  cases  are  returning  than 
formerly.  The  suture  of  the  nerves  is  easy  or  difficult,  depending  on 
the  amount  of  tissue  destruction  that  has  taken  place  in  the  neighbor- 
hood.   In  the  simple  rifle-bullet  wounds,  the  ends  of  the  nerves  are 


ARTIFICIAL  LIMBS  867 

easily  secured  and  approximated,  and  the  results,  as  demonstrated 
by  recovery  of  the  muscle,  very  satisfactory.  For  simple  wounds  in 
the  upper  part  of  the  arm  and  thigh  bones,  the  time  taken  for 
recovery  is  much  longer  than  supposed,  useful  muscle  power  rarely 
appearing  under  a  year  and  a  half.  The  wounds  of  nerves  compli- 
cated by  extensive  scarring  present  a  difficult  problem,  on  the  con- 
trary. Here  one  has  to  face  the  difficulty  of  finding  the  nerves,  of 
bridging  the  gap  frequently  produced  by  the  injury,  and  of  prevent- 
ing the  ingrowth  of  scar  tissue  to  such  a  degree  as  to  prevent  the 
downgrowth  of  the  axons.  The  results  in  these  cases,  except  in 
rare  instances,  have  been  far  from  satisfactory. 

What   is  meant  by   Group   G,    ''certain   complicated   gunshot 
injuries  to  joints,"  is  not  clear,  as  it  appears  to  overlap  Group  A. 

Group  H,  however,  is  very  definite,  and  provides  never-ending 
crowds  of  patients.  The  problem  of  caring  for  the  man  who  has  lost 
his  arm  or  leg  is  a  most  serious  one.  Not  only  is  it  the  business  of 
the  surgeon  to  see  that  the  stumps  are  healed  and  restored  to  the 
maximum  degree  of  usefulness,  but  he  must  prescribe  the  proper 
artificial  limb  for  each  of  the  cases,  and  superintend  the  instruction 
of  the  patient  in  its  use.  In  the  early  months  of  the  war  the  problem 
which  faced  us  was  not  fully  appreciated,  and  no  preparation  had 
been  made  for  the  reception  of  these  wounded  men.  The  result  was 
that  large  numbers  of  legless  and  armless  men  began  to  arrive,  and 
no  arrangements  had  been  made  for  supplying  artificial  limbs.  The 
only  couise  under  the  circumstances  was  to  order  the  limbs  from 
private  companies.  This  immediately  led  to  serious  trouble.  The 
convalescent  homes  were  invaded  by  the  agents  of  the  various 
companies,  and  the  men  and  officers  were  solicited  and  sometimes 
offered  commissions  on  orders  for  limbs.  The  Government  at  once 
recognized  that  this  state  of  things  could  not  continue,  and  that  some 
general  policy  must  be  evolved.  An  orthopedic  commission  was 
accordingly  appointed,  consisting  of  representative  surgeons,  along 
with  officers  of  the  A.  M.  C.  This  commission  decided  that,  as  it 
was  the  duty  of  the  Government  to  provide  its  crippled  soldiers  with 
the  best  artificial  limbs,  and  also  to  keep  them  so  provided  for  the 
rest  of  their  lives,  the  wisest  plan  would  be  for  the  Government  to 
undertake  the  manufacture  of  artificial  limbs.  This  plan  has  been 
adopted  and  is  working  out  satisfactorily.  A  large  artificial  limb 
factory  has  been  established  in  Toronto,  and  to  this  center  all  the 
amputation  cases  are  sent.  Here  the  stumps  are  allowed  to  heal, 
reamputations  are  performed  when  necessary,  stiffened  joints 
above  the  amputation  are  restored  to  motion,  atrophied  muscles 
are  strengthened  by  massage  and  therapeutic  exercise,  and  the 
stumps  are  shrunken,  preparatory  to  fitting  with  the  artificial  limb. 
When  the  limb  has  been  finished  in  the  rough,  the  patient  joins  a 
class  for  instruction  in  its  use,  and  during  the  period  of  three  or  four 
weeks  spent  in  this  manner,  the  necessary  changes  in  the  socket,  etc.. 


868  MILITARY  ORTHOPEDICS 

are  made  before  the  limb  is  finally  finished.  When  the  limb  has 
been  completed  to  the  satisfaction  of  the  limb-maker  and  the 
patient,  the  latter  presents  himself  before  the  surgeon  in  charge, 
and  he  is  either  given  his  discharge  from  the  artny,  after  which  he 
becomes  a  ward  of  the  Pensions'  Commission,  or  he  joins  the  classes 
in  vocational  training. 

The  problem  of  the  upkeep  of  the  artificial  limbs  is  important. 
Within  a  very  short  time  we  shall  have  all  sorts  of  repairs  to  make  in 
the  limbs,  and  later  the  limbs  will  have  to  be  renewed.  This  is 
a  serious  problem  when  it  is  remembered  that  the  patients  are 
scattered  all  over  the  country  from  Vancouver  to  Halifax.  To 
solve  it  the  Government  has  taken  into  the  artificial  limb  factory 
a  number  of  men  who  have  had  amputations  of  the  leg  and  were 
formerly  mechanics  of  some  sort,  and  has  apprenticed  them  to  the 
artificial  limb  trade.  W^hen  their  instruction  is  complete  it  is  pro- 
posed to  send  them  to  various  centers  tlu"oughout  the  Dominion, 
there  to  establish  small  stations,  where  small  repairs  can  be  per- 
formed and  where  measurements  can  be  taken  for  new  limbs,  and 
the  new  ones  properly  fitted  when  they  arrive  from  the  factory. 

From  our  experience  with  amputations  in  Toronto,  certain  con- 
clusions have  been  formed.  The  man  who  has  lost  a  leg  is  much 
better  off  than  the  man  who  has  lost  an  arm.  The  modern  artificial 
leg  is  really  an  excellent  apparatus,  imitating  extraordinarily  well 
the  function  of  the  normal  leg.  The  artificial  arm,  on  the  other  hand, 
is  a  very  poor  substitute  for  the  amputated  member.  The  contrast 
is  due  to  the  simplicity  of  the  movements  required  in  walking,  as 
against  the  highly  complicated  movements  of  the  fingers  and  hand. 
Whereas  the  man  who  has  lost  a  leg  can  frequently  return  to  his 
former  occupation  in  life,  the  armless  usually  has  to  make  a  change 
in  his  vocation.  While  a  good  deal  is  being  said  and  written  about 
armless  men  being  trained  to  use  artificial  arms  in  such  trades  as 
carpentry,  machine  shop  work,  etc.,  it  is  our  feeling  that  these  men 
will  never  be  able  to  compete  with  their  more  fortunate  fellows  in  the 
skilled  trades,  after  the  glory  of  the  war  has  passed  away.  It  is 
therefore  the  policy  of  the  vocational  officers  to  encourage  these 
men  to  take  up  new  or  allied  vocations,  in  which  the  handicap  of  the 
loss  of  an  arm  will  not  be  so  evident. 

Vocational  training  of  the  retm^ned  soldier  has  become  one  of  the 
great  national  responsibilities.  Although  the  problem  was  very 
haltingly  dealt  with  at  first,  it  has  now  become  a  national  institution. 
Every  military  hospital  center  is  provided  with  vocational  officers, 
instructors,  shops,  schools,  laboratories,  etc.,  all  aiming  at  restoring 
the  crippled  soldier  to  a  state  of  usefulness  to  the  community.  It 
has  been  recognized  that  nothing  helps  the  crippled  soldier  so  much 
as  to  make  him  able  to  help  himself.  When  the  soldier  is  sufficiently 
convalescent  to  become  interested  in  these  matters,  he  is  interviewed 
by  a  vocational  officer,  who  assists  him  in  deciding  what  is  the  best 


VOCATIONAL  TRAINING  869 

course  to  pursue  after  his  discharge  from  the  army.  Courses  in  the 
elementary  school  work,  preparatory  to  entry  into  the  civil  service, 
courses  in  telegraphy,  stenography,  mechanical  and  structural 
draughting  have  been  established,  and  are  well  attended.  In  the 
technical  schools  courses  in  carpentry,  machine-shop  work,  electricity 
and  so  on,  are  being  conducted  successfully.  Just  how  successful 
these  men  will  be  in  earning  a  livelihood  when  they  face  the  com- 
petition of  the  world  remains  to  be  seen,  but  the  present  indications 
point  to  a  great  lessening  of  the  evils  which  have  followed  the  dump- 
ing on  the  country  of  crowds  of  crippled  soldiers,  as  has  happened 
in  othel"  wars. 

The  importance  of  vocational  training  during  convalescence  is 
further  emphasized  in  the  following  remarks  of  Robert  Jones: 

"By  the  time  a  soldier  has  passed  through  various  phases  of 
recovery  from  septic  wounds  in  several  different  hospitals,  and  is 
finally  transferred  to  an  orthopedic  center  for  treatment  to  correct 
deformity  and  restore  the  use  of  injured  joints  and  muscles,  his 
spirit  is  often  broken.  The  shock  of  injury,  frequently  in  itself 
severe,  followed  in  succession  by  a  long  period  of  suppuration,  and 
then  by  a  wearisome  convalescence,  during  which  he  receives  treat- 
ment by  massage  or  electricity,  or  by  monotonous  movement  with 
mechanical  apparatus  of  the  Zander  type,  too  often  leaves  him  dis- 
contented with  hospital  life,  its  monotonous  round  of  routire,  and 
its  long  periods  of  idleness. 

In  the  orthopedic  center  he  finds  his  fellow-patients  busily 
engaged  in  employments  in  which  they  are  doing  something,  and  it  is 
not  many  days  before  he  asks  for  a  "job." 

In  the  Military  Orthopedic  Hospital  at  Shepherd's  Bush  alone, 
out  of  800  patients  about  500  are  employed  at  some  regular  work, 
which  fosters  habits  of  diligence  and  self-respect,  and  converts 
indolent  and  often  discontented  patients  into  happy  men,  who  soon 
begin  to  feel  that  they  are  becoming  useful  members  of  society  and 
not  mere  derelicts. 

Thus,  when  the  preliminary  stages  of  operative  and  surgical  treat- 
ment are  over,  there  is  a  steady  gradation  through  massage  and 
exercise  to  productive  work,  which  is  commenced  as  soon  as  the 
man  can  really  begin  to  use  his  limbs  at  all.  If  his  former  trade  or 
employment  is  a  suitable  one,  he  is  put  to  use  tools  he  understands, 
otherwise  some  occupation  suitable  for  his  disability,  and  curative 
inits  character,  is  found  for  him. 

Men  with  stiff  ankles  are  set  to  drive  a  treadle  lathe  or  fretsaw.  If 
put  on  a  treadle-exercising  machine  the  monotony  soon  wearies  the 
mind,  but  if  the  mind  is  engaged  not  on  the  monotony  of  the  foot- 
work, but  on  the  interest  of  the  work  turned  out,  neither  mind  nor 
body  becomes  tired. 

Men  with  defective  elbows  and  shoulders  find  exercise  and  mental 
diversion  in  the  carpenter's  and  blacksmith's  shops.    If  their  hands 


870  MILITARY  ORTHOPEDICS 

aiul  fingers  are  stiti',  working  witli  a  big  swab  to  clean  windows  or 
with  a  paint  brnsh  is  a  more  interesting  occupation  than  gripping 
spring  dumb-bells.  Those  of  us  who  have  any  imagination  cannot 
fail  to  realize  the  difference  in  atmosphere  and  morale  in  hospitals 
where  the  patients  have  nothing  to  do  but  smoke,  play  cards,  or  be 
entertained,  from  that  found  in  those  where  for  part  of  the  day 
they  have  regular,  useful  and  productive  work. 

INIassage  and  exercise  is  no  longer  a  mere  routine:  it  all  fits  in  and 
leads  up  to  the  idea  of  fitness — fitness  to  work  and  earn  a  living  and 
serve  the  State  in  an  economic  sense,  even  if  not  to  retm'n  to  the 
regiment  and  fight  once  more  in  the  ranks  of  the  army." 

It  will  appear  in  conclusion  that  military  orthopedics  may  be 
divided  into  three  main  classes : 

1.  The  disabilities  and  injuries  incident  to  civil  as  well  as  to 
military  life,  notably  the  various  aft'ections  of  the  feet,  the  injuries 
and  diseases  of  the  joints  and  bones,  all  of  which  with  the  exception 
of  fractures  have  been  described  at  length  in  the  preceding  chapters. 

As  to  fractures,  there  are  certain  primary  essentials  in  treatment 
to  which  attention  may  be  called.  Deformity,  and  particularly 
overriding  of  fragments,  should  be  immediately  corrected  under 
anesthesia,  and  normal  length  and  alignment  should  be  assured 
subsequently  by  measurement  and,  if  possible,  by  .r-ray  examina- 
tion. Security  is  best  assured  by  the  accurate  apposition  of  the 
fractured  surfaces,  but  in  certain  instances,  as,  for  example,  in 
fracture  of  the  shaft  of  the  femur,  both  splinting  and  traction  will 
be  required  to  prevent  subsequent  displacement.  The  Thomas 
knee  splint  arranged  for  direct  traction,  and  the  plaster  splint. 
Fig.  286,  combined  with  the  weight  and  pully  traction  are  the  most 
eftective  forms  of  apparatus.  At  the  hip-joint  the  fragments  should 
be  adjusted  and  fixed  by  the  abduction  method  as  described  in 
Chapter  XV,  and  the  same  method  may  be  employed  with  advan- 
tage for  fracture  of  the  upper  extremity  of  the  humerus. 

At  the  elbow,  acute  flexion  for  all  fractures  except  for  theolecranon, 
is  the  method  of  choice.  Forearm  fractures  should  be  treated 
in  full  supination  after  alignment  of  the  ulnar  has  been  secured. 

At  the  wrist  immediate  and  complete  reduction  of  deformity 
assures  security  if  the  injury  is  suitably  protected. 

At  the  ankle-joint  it  is  extremely  important  that  any  backward 
displacement  of  the  foot  should  be  corrected  and  that  it  be  fixed 
at  a  right  angle  to  the  leg  and  slightly  inverted. 

2.  This  class  includes  the  prevention  of  deformity  induced  by 
direct  and  indirect  injury  and  disease  of  bones,  joints,  muscles,  and 
nerves.  Also  of  the  parts  not  immediately  involved,  as  described  in 
this  and  preceding  chapters. 

3.  The  size  of  the  third  group  of  actual  reconstruction  depends 
in  great  degree  upon  the  quality  of  the  preceding  treatment,  and  em- 
phasizes the  importance  of  knowledge  of  the  immediate  and  remote 
causes  of  deformity  as  the  first  essential  of  effective  prevention. 


INDEX. 


Abbott  treatment  of  lateral  curvature 

of  spine,  210 
Abnormalities  of  ribs,  236 
Abnormality  of  clavicle,  238 
Abscess,  diagnosis  of,  from  tuberculous 
disease  of  spine,  59 
pelvic,  diagnosis  of,  from  tubercu- 
lous disease  of  spine,  46 
in  tuberculous  disease  of  spine, 
40 
perinephritic,    diagnosis    of,    from 

tuberculous  disease  of  spine,  46 
in  sacro-iliac  disease,  140 
in   tuberculous    disease   of   bones, 
255 
of  hip-joint,  379 

significance  of,  381 
statistics  of,  379 
treatment  of,  381 
of  joints,  255 
of  knee-joint,  428 
of  spine,  29,  51 
Absence  of  patella,  450 

treatment  of,  450 
of  ribs,  237 
Acetabulum  in  congenital  dislocation 

at  hip-joint,  531 
Achillobursitis,  740 
anterior,  740 
etiology  of,  740 
pain  in,  741,  742 
pathology  of,  741 
posterior,  742 
symptoms  of,  741 
treatment  of,  741 
operative,  742 
Achillodynia,  740 

Acquired  cerebral  paralysis   of  child- 
hood, 641 
deformities  in  cerebral  paralysis  in 

childhood,  645 
disability  in  cerebral  paralysis  in 

childhood,  646 
displacement  of  patella,  450 
genu  recurvatum,  446 

etiology  of,  446 
symptoms  of,  447 
synonyms  of,  446 
treatment  of,  447 
loss  of  growth  in  cerebral  paralysis 
in  childhood,  646 


Acquired  luxation  of  clavicle,  240 
treatment  of,  241 
talipes,  765,  820 

calcaneovalgus,  843 
treatment  of,  844 

arthrodesis  in,  857 
tendon  implantation 
in,  857 
transplantation 
in,  845 
calcaneovarus,  843 
treatment  of,  844 

arthrodesis  in,  857 
tendon  implantation 
in,  857 
transplantation 
in,  845 
calcaneus,  834 

deformity    in,     develop- 
ment of,  834 
etiology  of,  834 
symptoms  of,  834 
treatment  of,  835 

arthrodesis  in,  839 
astragalectomy      in, 

839 
backward     displace- 
ment in,  839 
Judson  brace  in,  836 
operative,  838 
silk  ligaments  in,  839 
tendon    fixation    in, 
839 
transplantation 
in,  839 
Whitman's  operation  in, 

839 
Willett's    operation    for, 
838  _ 
deformity  in,  development  of, 

820 
diagnosis  of,  from  congenital, 

821 
equino valgus,  831 
equino varus,  828 

treatment  of,  830 
equinus,  822 

deformity  in,    correction 
of,  825 
tonic  effect  of,  825 
etiology  of,  823 
symptoms  of,  824 
treatment  of,  824 


872 


INDEX 


Acquired    talipes    equinus,    treatment 
of,  arthrodesis  in, 
828 
astragalectomy  in, 

828 
backward  displace- 
ment in,  828 
operative,  828 
silk  ligaments  in,  828 
tendon  displacement 
828 
implantation  in, 
828 
etiology  of,  820 
valgus,  simple,  833 
torticollis,  660,  665 
varieties  of,  665 
Acromegaly,  528 
Acroparesthesia  of  foot,  744 
Actinomycosis  of  spine,  121 
Acute  anterior  poliomyelitis,  610.     See 

Poliomyelitis,  acute  anterior. 
Ambulatory  supports  in  treatment  of 

tuberculous  disease  of  spine,  70 
Amputation  in  treatment  of  tubercu- 
lous disease  of  liip-joint, 
388 
of  knee-joint,  432 
Anchylosis  of  ankle-joint,  treatment  of, 
303 
of  hip- joint,  treatment  of,  303 
of  joints,  299 

etiology  of,  299 
pathology  of,  299 
prevention  of,  299 
treatment  of,  299 

arthroplasty  in,  302 
forcible  correction  in,  300 
operative  exploration  in, 

302 
passive  motion  in,  299 
of  knee-joint,  treatment  of,  303 
Angioneurotic  edema  of  foot,  744 
Ankle-joint,  anchylosis  of,  treatment  of, 
303 
arthritis  deformans  of,  diagnosis  of, 

from  tuberculosis,  461 
infectious  arthritis  of,  diagnosis  of, 

from  tuberculosis,  461 
injury  of,  465 
range  of  motion  at,  702 
sprain  of,  465 
chi'onic,  468 

treatment  of,  468 
diagnosis  of,  from  tuberculo- 
sis, 461 
etiology  of,  465 
pain  in,  466 
symptoms  of,  466 
treatment  of,  466 

adhesive    plaster    strap- 
ping in,  466 
stockinette    bandage    in, 
467 


Ankle-joint,  tuberculous  disease  of,  455 
age  in,  457 
deformity  in,  458 

reduction  of,  461 
diagnosis  of,  459 

from  arthritis  deformans, 

461 
from  flat-foot,  461 
from  infectious  arthritis, 

461 
from  rheumatism,  461 
from  sprains,  461 
etiology  of,  456 
limp  in,  458 
pathology  of,  455 
prognosis  of,  463 
situation  of,  456 
stiffness  in,  458 
symptoms  of,  457 
treatment  of,  461 
operative,  462 
Thomas's  brace  in,  461 
Ankles,  swelling  about,  472 
Anterior  achdUobursitis,  740 
bow-legs,  607 

symptoms  of,  607 
treatment  of,  607 

osteotomy  in,  607 
congenital  dislocation  at  hip-joint, 

537 
curvature  of  tibia,  607 
displacement  of  tibia,  447 
metatarsal     arch,    depression    of, 
732 
weakness  of,  732 
metatarsalgia,  732 
etiology  of,  733 
gout  and,  737 
heredity  in,  737 
influence  of   shoe  in  causing 

disability  and  pain,  736 
pathology  of,  733 
rheumatism  and,  737 
treatment  of,  738 
poliomyelitis,  610.     See  Poliomye- 
litis, acute  anterior. 
Appendicitis,  diagnosis  of,  from  tuber- 
culosis of  spine,  46 
Ai-an-Duchenne  type  of  paralysis,  651 
Arborescent    synovial    tuberculosis    of 

joints,  258 
Arches  of  foot,  680 

Arm,  muscles  of,  paralysis  of,  in  acute 
anterior  poliomyelitis,  treatment  of, 
631 
Arthrectomy  in  treatment  of  tubercu- 
lous disease  of  knee-joint,  430 
Arthritis,  274 

atrophic,  287 

etiology  of,  290 
treatment  of,  290 
deformans,  283 

of    ankle-joint,    diagnosis    of, 
from  tuberculosis,  461 


INDEX 


873 


Arthritis  deformans  of  great  toe,  748 
of  hip-joint,  404 

diagnosis  of,  from  tuber- 
culosis, 331 
of    knee-joint,    diagnosis    of, 
from  tuberculosis,  419 
degenerative,  283 
etiology  of,  285 
pain  in,  287 
pathology  of,  283 
symptoms  of,  287 
treatment  of,  287 
diagnosis  of,  from  tuberculous  dis- 
ease of  spine,  59 
gonorrheal,  274 

distribution  of,  274 
of  hip-joint,  401 

diagnosis  of,  from  tuber- 
culosis, 331 
in  infancy,  276 
purulent,  275 
serofibrinous,  275 
serous,  275 
symptoms  of,  275 
treatment  of,  276 
of  hip-joint,  acute  infectious,  400 
symptoms  of,  400 
treatment  of,  400 
hypertrophic,  283 
etiology  of,  285 
pain  in,  287 
pathology  of,  283 
symptoms  of,  287 
treatment  of,  287 
in  infancy,  278 

etiology  of,  278 
prognosis  of,  278 
sex  in,  278 
symptoms  of,  278 
treatment  of,  279 
infectious,  of  anlde-joint,  diagnosis 
of,  from  tuberciilosis,  461 
diseases  and,  277 
prognosis  of,  277 
treatment  of,  277 
of  hip-joint,  diagnosis  of,  from 
congenital  disloca- 
tion, 539 
from  tuberculosis,  331 
of  knee-jerk,  diagnosis  of,  from 
tubercidosis,  419 
proliferating,  283,  287 
etiology  of,  290 
treatment  of,  290 
puerperal,  276 
rheumatoid,  283 
scarlatina  and,  277 
of  spine,  124 

treatment  of,  124 
subacute,  of  hip-joint,  401 
tuberculous,  279 
typhoid  fever  and,  277 
Arthrodesis  in  treatment  of  acute  ante- 
rior poliomyelitis,  639 


Arthrodesis  in  treatment  of  acquired 
talipes      calcaneo- 
valgus,  857 
calcaneovarus,  857 
calcaneus,  839 
equinus,  828 
of  paralytic  talipes,  839 
Arthropathy,  tabetic,  295 
diagnosis  of,  298 
distribution  of,  298 
pathology  of,  296 
symptoms  of,  297 
treatment  of,  298 
Arthroplasty  in    treatment  of    anchy- 
losis of  joints,  302 
Arthrotomy  in  congenital  dislocation 

at  hip-joint,  555 
Ashley's  details  of  1000  cases  of  tuber- 
culosis of  hip-joint,  335 
Astragalectomy    in    treatment    of   ac- 
quired talipes  cal- 
caneus, 839 
equinus,  828 
of  neglected  talipes,  806 
of  paralytic  talipes,  839 
Astragalonavicular   joint,    tuberculous 

disease  of,  459 
Asymmetrical    development    of   body, 

241 
Ataxia,  hereditary,  654 
Atlo-axoid  articulation,  range  of  motion 

at,  55 
Atrophic  arthritis,  287     . 
etiology  of,  290 
treatment  of,  290 
Atrophy  of  bone,  247 
in  coxa  vara,  567 
myelopathic,  651 
progressive  muscular,  651 
in  tuberculous  disease  of  elbow- 
joint,  478 
of  hip-joint,  319 
of  shoulder-joint,  475 
of  wrist-joint,  482 


B 


Baker's  knee,  586 
Back,  fiat,  229 

knee,  446.     See  Genu  recurvatum. 
pain  in,  135 

treatment  of,  136 
round,  228 

hollow,  229 
strain  of,  diagnosis  of,  from  tuber- 
culous disease  of  spine,  43 
Backward  displacement  in   treatment 
of  acquired  talipes 
calcaneus,  839 
equinus,  828 
of  paralytic  talipes,  839 
"Baseball  finger,"  506 

treatment  of,  506 


874 


IXDEX 


Beck's    preparation    in    treatment    of 

tuberculous  disease  of  bones,  265 
Bier's  hyperemia  in  treatment  of  tuljer- 
culous  disease  of  joints,  266 
treatment  of  tuberculous  disease  of 
knee-joint,  427 
Bilateral  congenital  dislocation  at  hip- 
joint,  535 
diagnosis  of,  from  tuber- 
culous disease  of  spine, 
45 
coxa  vara,  567 
disease  of  hip,  377 

treatment  of,  378 
Billroth  splint  in  treatment  of  tubercu- 
lous disease  of  knee-joint,  -422 
Body,    as^Tnmetrical   development    of, 

241 
Bones,  atrophy  of,  247 
carcinoma  of,  304 
of  foot,  supernumerary.  757 
hj'pertrophy  of,  248 
of  lower  extremitv,  deformities  of, 
583 
etiolog}'  of,  583 
statistics  of,  583 
malignant  disease  of,  304 
metatarsal,  fractirre  of,  757 
treatment  of,  757 
multiple  myeloma  of,  522 
tarsal,  fracture  of,  469 

treatment  of,  469 
■  .r-rays  in.  469 
tuberculous  disease  of,  249 
abscess  in,  255 
age  in,  253 
diagnosis  of,  262 

.r-rays  in,  262 
distribution  of,  252  | 

dry  caries  in,  259 
etiology  of,  249 
latent,  249 

mode  of  infection  in,  249 
patholog^'  of,  254 
predisposition  to,  249,  251 
prognosis  of,  260 
repair  in,  259 
septic  infection  in,  259 
sex  in,  253 
side  affected  in,  253 
treatment  of,  262 

Beck's  preparation  in,265 
drugs  in.  264 
iodoform  filling  in.  265 
mechanical.  264 
operative,  264 
sunlight  in,  262 
-C-rays  in,  266 
tumors  of,  304 
Bow-leg,  583,  602 
anterior,  607 

sjTnptoms  of,  607 
treatment  of,  607 
"  osteotomy  in,  607 


Bow-leg,  deformity  in,  etiologj'  of,  583 
onset  of.  584 
outgrowth  of,  586 
predisposition  to,  584 
statistics  of,  583 
diagnosis  of,  from  congenital  dis- 
location of  hip,  539 
gait  in,  604 
measurements  in,  604 
sj-mptoms  of,  604 
treatment  of,  604 
braces  in,  604 
Ivnight,  605 
Xapier.  605 
expectant,  604 
operative,  606 
osteoclasis  in,  606 
osteotomj^  in,  606 
Brace,  caliper,  in  treatment  of  tuber- 
culous    disease    of    knee-joint, 
426 
Judson,  in  treatment  of  acquired 
talipes  calcaneus,  836 
of   acute   anterior   polio- 
myelitis, 627 
of  neglected  talipes,  809 
of  parahi:ic  talipes,  836 
of  tuberculous  disease  of 
hip,  343 _ 
Taylor's  club-foot,  /85 

in    treatment   of   tuberculous 
disease  of  Inp,  343,  371 
of  tuberculous  disease  of 
spine,  85 
Thomas's  caliper,  in  treatment  of 
acute  anterior  poliomyelitis, 
634 
knock-knee,   in  treatment  of 
acute  anterior  poliomyelitis, 
634 
in  treatment  of  genu  valgum, 
596 
of  knock-knee,  596 
of  tuberculous  disease  of 
ankle-joint,  461 
of    knee-joint,    423, 
424 
in  treatment  of  bow-legs,  604 
of  genu  varum,  604 
of  infantile  talipes,  781 
of  weak  foot,  715 
Brachial  plexus,  obstetrical  injury  to, 

repair  of.  495 
Bradford   bed   frame   in  treatment  of 
tuberciilous  disease  of  spine,  63 
brace  in  treatment  of  tuberculous 
disease  of  hip-joint,  343 
Bradford-Goldthwait  genuclast,  for  flex- 
ion deformity  at  knee,  423 
Brain,  decompression  of,  in  treatment 
of  cerebral  parah'sis  of  childhood,  650 
Bunion,  754 

Bm-sa,  superficial  pretibial,  enlargement 
of,  445 


INDEX 


875 


Bursse,  diseases  of,  diagnosis  of,  from 
tuberculosis  of  hip-joint,  332 
in  popliteal  region,  446 
Bursitis,  444 

of  hip- joint,  gluteal,  403 

treatment  of,  403 
iliopsoas,  403 

treatment  of,  403 
prepatellar,  444 

treatment  of,  444 
pretibial,  445 

symptoms  of,  445 
treatment  of,  445 
retrocaljpaneo-,  740 
of  shoulder-joint,  chronic,  487 


C'alcaneobursitis,  743 
Caliper  brace  in  treatment  of  tubercu- 
lous disease  of  knee-joint,  426 
Calot  jacket  in  treatment  of  tubercu- 
lous disease  of  spine,  76 
Calot's  fluid  in  treatment  of  tuberculous 

disease  of  joints,  265 
Campbell  brace  in  displacement  of  semi- 
lunar cartilage,  442 
Caput  quadratum  in  rachitis,  511 
Carcinoma  of  bone,  304 
of  femur,  403 
of  spine,  119 

diagnosis  of,  120 
Caries  sicca,  259 

Cerebral  paralysis  of  childhood,  641 
acquired,  641 

after  birth,  642 
deformities  in,  645 
disability  in,  646 
during  labor,  642 
intra-uterine,  641 
loss  of  growth  in,  646 
congenital,  641 

deformities  in,  644 
mentahty  in,  645 
weakness  in,  643 
diagnosis  of,  from    acute 
anterior    poliomyelitis, 
615 
distribution  of,  641 
etiology  of,  641 
pathology  of,  641 
prognosis  of,  650 
symptoms  of,  642 
mental,  642 
motor,  642 
treatment  of,  646 

decompression  of 
brain  in,   650 
of  hemiplegia,  646 
muscle    transplanta- 
tion in,  647 
operative,  649 
of  paraplegia,  648 


Cerebrospinal  meningitis,  diagnosis  of, 
from  tuberculous  disease  of  spine,  60 
Cei'vical  opisthotonos,  678 

diagnosis  of,  from  tuberculous 
disease  of  spine,  58 
ribs,  236 
Charcot-Marie-Tooth  type  of  paralysis, 

651 
Charcot's  disease  of  joints,  295 
diagnosis  of,  298 

from  tuberculosis, 
419 
distribution  of,  298 
pathology  of,  296 
symptoms  of,  297 
treatment  of,  298 
Chest  in  childhood,  table  of  circumfer- 
ence of,  242 
deformities  of,  238 

minor,  240 
flat,  238 

treatment  of,  238 
funnel,  239 
keel-shaped,  239 
pigeon,  239 
Chondrodystrophia,  517 
etiology  of,  518 
pathology  of,  518 
prognosis  of,  520 
treatment  of,  520 
Clavicle,  abnormality  of,  238 
luxation  of,  acquired,  240 
treatment  of,  241 
subluxation  of,  240 
treatment  of,  241 
Club-hand,  502 

etiology  of,  502 
treatment  of,  503 
Club-foot  brace,  Taylor,  785 
congenital,  765 

anatomy  of,  772 
etiology  of,  765 
statistics  of,  770 
symptoms  of,  776 
treatment  of,  776 
neglected,  treatment  of,  788 
Coccygodynia,  143 

treatment  of,  143 
Compound  deformities  of  foot,  764 
Congenital   absence   of   fibula,  talipes 
equinovalgus  and,  814 
etiology  of,  816 
statistics  of,  815 
treatment  of,  816 
of  tibia,  talipes  equino varus 
and,  816 
varus  and,  816 
cerebral  paralysis  of  childhood,  641 
club-foot,  765 

anatomy  of,  772 
etiology  of,  765 
statistics  of,  770 
symptoms  of,  776 
treatment  of,  776- 


876 


INDEX 


Congenital  contraction  of  fingers,  504 
treatment  of,  505 
of  knee,  454 

prognosis  of,  454 
treatment  of,  454 
deficiency  of  femur,  818 
deformities  at  elbow,  498 

at  wrist,  501 
dislocation  at  hip-joint,  529 
acetabulum  in,  531 
anterior,  537 
arthrotomy  in,  555 
bilateral,  535 

diagnosis    of,     from 
tuberculous  disease 
of  spine,  45 
capsule  in,  531 
diagnosis  of,  538 

from  bow-legs,  539 
from  coxa  vara,  539 
from  infectious    ar- 
thritis, 539 
epiphysitis,  539 
from  progressive  mus- 
ciilar     dystrophy, 
539 
from  tuberculosis,  333 
from  tuberculous  dis- 
ease of  spine,  539 
etiology  of,  533 
femiir  in,  532 
Hoffa-Lorenz     operation 

for,  556 
in  infancy,  treatment  of, 

549 
ligamentum  teres  in,  531 
limp  in,  535 

Lorenz  operation  for,  540 
reduction  in,541 
in  two  sit- 
tings, 544 
in    young 
subjects, 
_  544 
traction  in,  543 
muscles  in,  533 
in  older  subjects,  treat- 
ment of,  553 
open  operation  with  en- 
largement of  acetabu- 
lum in,  556 
osteotomy  in,  555 
pain  in,  536 
pathology  of,  530 
pelvis  in,  532 
prognosis  of,  552 
sailor  gait  in,  536 
statistics  of,  529 
supracotyloid,  538 
symptoms  of,  534 

general,  536 
treatment  of,  540 
paUiative,  561 
review  of,  558 


Congenital    dislocation    at    hip-joint, 
treatment     of,    varia- 
tions in,  549 
unilateral,  535 
waddle  in,  536 
of  knee,  454 
of  shoulder,  489 
displacement  of  patella,  450 
of  phalanges  of  fingers,  505 
of  radius,  498 
of  uhia,  498 
distortions  of  hand,  502 
elevation  of  scapula,  234 
etiology  of,  235 
treatment  of,  235 
exostoses  of  foot,  757 
genu  recmrvatum,  447 

deformities  of,  absence  of 
patella,  449 
dislocation  of  hip,  449 
valgus,  448 
varus,  448 
etiology  of,  449 
synonym  of,  447 
treatment  of,  449 
hallux  varus,  749 
hammer-toe,  755 
hypertrophy  of  feet,  819 
lateral  curvatm-e  of  the  spine,  162 
pronation  of  forearm,  498 

treatment  of,  498 
subluxation  of  hip,  561 
syphihs  of  joints,  271 
talipes,  765 

calcaneovalgiis,  814 
calcaneo varus,  814 
calcaneus,  813 
cavus,  814 
eqiiino valgus,  814 
equinovarus,  772,  814 

treatment   of,    principles 
of,  review  of,  810 
equinus,  813 
valgocavus,  814 
valgus,  814 
varus,  812 
torticoUis,  660,  661 
etiology  of,  663 
hematoma    of    sternomastoid 

and,  663 
pathology  of,  665 
Constricting  bands  of  feet,  819 
Contracted  foot,  728 

etiology  of,  728 
symptoms  of,  729 
treatment  of,  731 
operative,  731 
Contraction  of  fingers,  congenital,  504 
treatment  of,  505 
of  knee,  congenital,  454 

prognosis  of,  454 
treatment  of,  454 
Convex  stretcher  frame  in  treatment  of 
tuberculous  disease  of  spine,  63 


INDEX 


877 


Corsets   in   treatment   of    tuberculous 

disease  of  spine,  84,  85 
Cough  in  tuberculous  disease  of  spine, 

50 
Coxa  valga,  582 
vara,  562 

atrophy  in,  567 
awkwardness  in,  567 
bilateral,  567 
deformity  in,  567 

mechanical  predisposition 
to,  564 
diagnosis  of,  569 

from  congenital  disloca- 
tion of  hip,  539,  570 
from  hip  disease,  569 
from  tuberculous  disease 
of  hip-joint,  332 
discomfort  in,  567 
etiology  of,  563 
limitation  of  motion  in,  567 
Ump  in,  567 

mechanical  effects  of,  565 
osteotomy  for,  572,  573 
pathology  of,  562 
physical  effects  of,  567 
shortening  in,  567 
symptoms  of,  565 
synonym  of,  562 
traumatic,  574 

diagnosis  of,  from  tuber- 
culous disease  of  hip- 
joint,  333 
treatment  of,  571 

cuneiform  osteotomy  in, 

573 
forcible  abduction  in,  572 
linear  osteotomy  in,  572 
operative,  572 
imUateral,  567 
Craniotabes  in  rhachitis,  511 
Cretinism,  520 
Cubitus  valgus,  498 

in  rhachitis,  512 
varus,  498 

in  rhachitis,  512 
Cuneiform  osteotomy  in  treatment  of 
genu  valgum,  600 
of  knock-knee,  600 
of  neglected  talipes,  806 
Cysts  of  femur,  404 

treatment  of,  404 
in  popUteal  region,  446 


Decompression  of  brain  in  treatment 
of  cerebral  paralysis  of  childhood,  650 
Deformities  acquired  in  cerebral  par- 
alysis in  childhood,  645 
in  acute  anterior  poliomyehtis,  620, 

622 
of  bones  of  lower  extremity,  583 


Deformities  of  bones  of  lower  extrem- 
ity,    etiology    of, 
583 
statistics  of,  583 
of  chest,  238 

minor,  240 
in  congenital  cerebral  paralysis  of 

childhood,  644 
of  elbow,  congenital,  498 
of  foot,  680,  763 

compound,  764 
hysterical,  654 
of  knee-joint,  437 
in  rhachitis,  510 
of  upper  extremity,  489 
at  wrist,  congenital,  501 
Deformity  in  acquired  talipes,  develop- 
ment of,  820,  834 
in    acute    anterior    poliomyelitis, 

causes  of,  617 
in  coxa  vara,  567 
functional  pathogenesis  of,  242 

Wolff's  law  of,  242 
of  legs,  weak  foot  in  childhood  and, 

708 
in  paralytic  talipes,  834 
in   tuberculous   disease  of   ankle- 
joint,  458 
of  elbow-joint,  478 
Degenerative  arthritis,  283 
etiology  of,  285 
pain  in,  287 
pathology  of,  283 
symptoms  of,  287 
treatment  of,  287 
Depression  of  anterior  metatarsal  arch, 
732 
of  neck  of  femur,  562 
Deviation  in  lateral  cm-vature  of  spine, 
147 
of  spine  in  tuberculosis,  51 
Diphtheritic    paralysis,    diagnosis    of, 
from     acute     anterior 
poliomyehtis,  616 
from  tuberculous  disease 
of  spine,  60 
torticolhs  and,  678 
Disabilities  of  foot,  680 
Dislocation     at   hip-joint,    congenital, 
529 
acetabulum  in,  531 
anterior,  537 
arthrotomy  in,  555 
bilateral,  535 
capsiile  in,  531 
diagnosis  of,  538 

from  bow-legs,  539 
from  coxa  vara,  539 
from  infections,  ar- 
thritis, 539 
epiphysitis,  539 
from    progressive 
muscular    dystro- 
phy, 539 


878 


INDEX 


Dislocation    at    hip-joint,    congenital, 
diagnosis       of,      from 
tuberculous  diseases  of 
spine,  45,   539 
etiology  of,  533 
femiu-  in,  532 
genu  recurvatum  and, 449 
HofTa-Lorenz      operation 

for,  556 
in  infancj',  treatment  of, 

549 
ligamentum  teres  in,  531 
limp  in,  535 

Lorenz  operation  for,  540 
reduction  in,  541 
in  two   sit- 
tings, 544 
in     young 
subjects, 
544 
traction  in,  543 
muscles  in,  533 
in  older   subjects,   treat- 
ment of,  553 
open  operation  \\atli  en- 
largement of  acetubu- 
Imn  in,  556 
osteotomy  in,  555 
pain  in,  536 
pathology  of,  530 
pelvis  in,  532 
prognosis  of,  552 
sailor  gait  in,  536 
symptoms  of,  534 

general,  536 
statistics  of,  529 
supracotyloid,  538 
treatment  of,  540 
palhative,  561 
review  of,  558 
variations  in,  549 
unilateral,  535 
waddle  in,  536 
spontaneous,  401 

treatment  of,  402 
of  knee,  congenital,  454 
of  shoulder,  congenital,  489 
recurrent,  497 

treatment  of,  497 
operative,  497 
Disjjlacement  of  patella,  acquired,  450 
congenital,  450 
of  peronei  tendons,  758 

treatment  of,  758 
of  phalanges  of  fingers,  congenital, 

505 
of  radius,  congenital,  498 
of  semilmiar  cartilage,  440 

Campbell  brace  in,  442 
Griffith's  brace  in,  441 
pain  in,  440 
treatment  of,  441 
tibia,  anterior,  447 
of  ulna,  congenital,  498 


Distortions  in  acute  anterior  poliomye- 
litis, compensatory,  623 
of  fingers,  505 
of  hand,  congenital,  502 
of  limbs  in  tuberculous  disease  of 
hip-joint,  312 
DoUinger  on  retardation  of  growth  in 
tuberculous  disease  of  hip-joint,  323 
Dorsiflexed  foot,  764 
Drop-finger,  506 

Dry  caries  in   tuberculous  disease  of 
bones,  259 
of  joints,  259 
Dupuytren's  contraction,  506 
etiologj"  of,  506 
pathology  of,  506 
symptoms  of,  507 
treatment  of,  507 
Dysbasia  angiosclerotica,  745 
Dyschondroplasia,  520 

.r-rays  in,  520 
Dystrophies,    muscular,    diagnosis    of, 
from  tuberculous  disease  of  spine,  45 
D3^strophy,  musciilar,  652 


E 


Edema,  angioneurotic,  of  foot,  744 
Elbow,  deformities  of,  congenital,  498 
Elbow-joint,  tuberculous  disease  of,  477 
age  in,  477 
atrophy  in,  478 
deformity  in,  478 

reduction  of,  480 
occmTence  of,  477 
pain  in,  478 
pathology  of,  477 
prognosis  of,  480 
sensitiveness  in,  478 
stiffness  in,  478 
swelling  in,  478 
SA'mptoms  of,  478 
treatment  of,  479 
excision  in,  480 
operative,  480 
Electrical  test  in  acute  anterior  polio- 
myelitis, 616 
Elongation  of  ligaments  of  patella,  453 
etiology  of,  453 
symptoms  of,  453 
treatment  of,  453 
Empj^ema,  diagnosis  of,  from  tubercu- 
lous disease  of  spine,  52 
Enlargement    of    superficial    pretibial 

bm'sa,  445 
Epiphj'seal  fractm-e,  diagnosis  of,  from 
tuberculous  disease  of  hip- 
joint,  333 
of  neck  of  femur,  576 

treatment  of,  576 
Epiphysitis  at  hip-joint,  acute,  400 
symptoms  of,  400 
treatment  of,  400 


INDEX 


879 


Epiphysitis  at  hip-joint,  diagnosis  of , 
from  tuberculous  disease  of 
hip-joint,  331 
infectious,  diagnosis  of,  from 
congenital  dislocation,  539 
Equinus,  postural,  728 
Erythromelalgia  of  foot,  744 
Everted  foot,  764 

Excision  in  treatment  of  tuberculous 
disease  of  elbow-joint, 
480 
of  knee-joint,  431 
of  genu  valgum,  596 
Exercise  in  treatment  of  knock-knee, 
596  " 
in  treatment  of  weak  foot,  711 
Exostoses  of  foot,  756 

congenital,  757 
subungual,  757 
treatment  of,  757 
Extended  and  everted  foot,  764 
and  inverted  foot,  764 
foot,  764 
Extra-articular  disease  of  hip-joint,  402 
tuberculous  disease  of  knee- 
joint  and,  428 


Feet,  congenital  hypertrophy  of,  819 

constricting  bands  of,  819 
Femur,  carcinoma  of,  403 

congenital  deficiency  of,  818 

dislocation  at  hip-joint,  532 
cysts  of,  404 

treatment  of,  404 
neck  of,  depression  of,  562 
fracture  of,  574 

in  adult  life,  577 

treatment  of, 
578 
in  childhood,  diagnosis  of, 
from   tuberculous    dis- 
ease of  hip-joint,  333 
epiphyseal,  576 

treatment  of,  576 
ox)en  operation  for,  581 
simple,  575 

diagnosis  of,  575 
treatment  of,  576 
sarcoma  of,  403 
Fibula,  congenital  absence  of,  talipes 
equinovalgus 
and,  814 
etiology  of,  816 
statistics  of,  815 
treatment  of ,  8 1 6 
Finger,  baseball,  506 

treatment  of,  506 
hammer,  504 
jerking,  505 
mallet,  506 

treatment  of,  506 


Finger,  snapping,  505 
trigger,  505 

etiology  of,  505 

synonyms  of,  505 

treatment  of,  506 
Fingers,  contraction  of,  congenital,  504 
treatment  of,  505 
distortions  of,  505 
phalanges  of,  congenital  displace- 
ment of,  505 
webbed,  505 

etiology  of,  505 

treatment  of,  505 
Flat  back,  229 
chest,  238 

treatment  of,  238 
foot,  693 

diagnosis  of,  from  tuberculous 
disease  of  ankle-joint,  461 
Flexed  and  everted  foot,  764 

and  inverted  foot,  764 
Foerster's   operation  for  cerebral  par- 
alysis of  childhood,  649 
Foot,  acroparesthesia  of,  744 
in  activity,  684 
angioneurotic  edema  of,  744 
arches  of,  680 

anterior  metatarsal,  682 

internal,  682 

longitudinal,  680 

transverse,  680 
as  a  mechanism,  692 
as  a  passive  support,  682 
bones  of,  supernumerary,  757 
contracted,  728 

etiology  of,  728 

sjTxiptoms  of,  729 

treatment  of,  731 
operative,  731 
deformities  of,  680,  763 

compound,  764 
disabilities  of,  680 
dorsiflexed,  764 
erythromelalgia  of,  744 
everted,  764 
exostoses  of,  756 

congenital,  757 

subungual,  757 

treatment  of,  757 
extended,  764 

and  everted,  764 

and  inverted,  764 
flat,  693 
flexed  and  everted,  764 

and  inverted,  764 
functions  of,  680 

hollow,  728.    See  Foot,  contracted, 
invei-ted,  764 
movements  of,  684 
muscles  of,  function  of,  689 
plantar  flexed,  764 
postures  of,  improper,  684 
pronated,  693 
Raynaud's  disease  of,  745 


880 


INDEX 


Foot,  splay,  693 

vasomotor  trophic  neiu'oses  of,  744 
weak,  693 

in  childhood,  706 

deformity  of  legs  and,  708 
general     weakness     and, 

708 
irregular  forms  of,  708 
sjonptoms   of,    in-toeing, 
707 
out-toeing,  707 
outgrown  joints,  707 
weak  ankles,  707 
diagnosis  of,  700 

attitudes  in,  700 
bearing  sm-face  of,  702 
contour  in,  701 
distribution    of    weights 

and  strain  in,  701 
range  of  motion  of,  702 
etiology  of,  696 
limitation  of  motion  in,  704 
muscular  spasm  in,  704 
pathology  of,  698 
re^'iew  of,  709 
rigid,  718 

treatment  of,  718 
adjuncts  in,  724 
manipulation  in,  721 
overcorrection    in, 
forcible,  719 
f  unct  ional  use  in, 
720 
plaster  strapping,724 
Thomas's,  724 
varieties  of,  723 
statistics  of,  697 
symptoms  of,  698 
treatment  of,  710 
attitudes  in,  711 
brace  in,  715 

construction  of,  713 
exercises  in,  711 
operative,  726 
plaster  cast  in,  713 
shoe  in,  710 

raising  inner  border 
of,  711 
support  in,  712 
tj^pes  of,  705 

persistent  abduction,  705 
pes  planus,  705 
varieties  of,  704 
Forearm,  pronation  of,  congenital,  498 

treatment  of,  498 
Fracture,  epiphyseal,  diagnosis  of,  from 
tuberculous  disease  of  liip-joint, 
333 
of  metatarsal  bones,  757 

treatment  of,  757 
of  neck  of  femm%  574 

in  adult  hie,  577 

treatment  of, 
578 


Fracture  of  neck  of  femui"  in  child- 
hood, diagnosis  of,  from 
tuberculous    disease  of 
hip-joint,  333 
epiphj-seal,  576 

treatment  of,  576 
open  operation  for,  581 
simple,  574 

diagnosis  of,  575 
treatment  of,  576 
of  tarsal  bones,  469 

treatment  of,  469 
x-rays  in,  469 
of  thigh  in  infants,  582 
Fragihtas  ossium,  522 

treatment  of,  522 
Friedreich's  disease,  654 
Functional  pathogenesis  of  deformitv, 
242 
Wohf's  law  of,  242 
Fimctions  of  foot,  680 
Funnel  chest,  239 


Gait  in  bow-legs,  604 
in  genu  valgum,  592 

varum,  604 
in  knock-knee,  592 
Genu  recurvatum,  acquired,  446 
etiolog}'  of,  446 
sjTnptoms  of,  447 
sjmonym  of,  446 
treatment  of,  447 
congenital,  447 

deformities  of,  absence  of 
patella,  449 
dislocation  of  hip, 

449 
valgiis,  448 
varus,  448 
etiology  of,  449 
sjTionym  of,  447 
treatment  of,  449 
traumatic,       treatment      of, 

447 
tuberculous    disease    of    hip- 
joint  and,  398 
valgum,  583,  589 

accommodative    attitude    in, 

591 
adolescent,  590 
attitude  of  rest  in,  585 
changed  relation  of  femur  and 

tibia  in,  591 
deformitv  in,    outgTO-^-th   of, 
586 
predisposition  to,  584 
secondary',  591 
etiology  of,  583 
gait  in,  592 
measurements  in,  593 
onset  of,  584 


INDEX 


881 


in, 


Genu  valgum,  pathology  of,  594 
symptoms  of,  590 
treatment  of,  595 
braces  in,  596 

duration  of,  599 
Thomas's,  596 
cuneiform  osteotomy 

600 
exercise  in,  596 
expectant,  595 
manipulation  in,  596 
operative,  599 
osteoclasis  in,  601 
osteotomy  in,  599 
posture  in,  596 
*       Wolff's,  601 
unilateral,  592 

with  genu  varum  and  general 
rhachitis  distortions,  593 
varum,  583,  602 

deformity   in,    outgrowth   ot, 
586 
predisposition  to,  584 
etiology  of,  583 
gait  in,  604 
measurements  in,  604 
onset  of,  584 
statistics  of,  583 
symptoms  of,  604 
treatment  of,  604 
braces  in,  604 
Ivnight,  605 
Napier,  605 
expectant,  604 
operative,  606 
osteoclasis  in,  606 
osteotomy  in,  606 
Gluteal  bursitis  of  hip-joint,  403 

treatment  of,  403 
Gonorrheal  arthritis,  274 

distribution  of,  274 
of  hip-joint,  401 

diagnosis  of,  from  tuber- 
culosis, 331 
in  infancy,  276 
purulent,  275 
serous,  275 
serofibrinous,  275 
symptoms  of,  275 
treatment  of,  276 
rheumatism,  274 
of  spine,  124 

treatment  of,  124 

Gout,  292  ,  .  , 

anterior        metatarsalgia         and, 

737 
Morton's  neuralgia  and,  737 
pathology  of,  293 
Grattan's  osteoclast,  601 
Griffith's  brace  in  displacement  ot  semi- 
lunar cartilage,  441 
"Growing  pains,"    diagnosis   ot,   from 
tuberculous     disease     of     hip-]omt, 
330 
56 


H 


Hallux  fiexus,  746 
rigidus,  746 

etiology  of,  746 
treatment  of,  746 
valgus,  751 

etiology  of,  751 
pathology  of^  751 
shoes  and,  751 
symptoms  of,  752 
treatment  of,  752 
operative,  753 
varus,  749 
'  congenital,  749 

I  treatment  of,  749 

I  Hammer-finger,  504 
toe,  754 

congenital,  755  _^ 
symptoms  of,  755 
'  treatment  of,  755 

Hand,  congenital  distortions  of,  502 
Harrison's  groove  in  rhachitis,  511 
Heberden's  nodes,  287 
Heel,  painful,  743 

pain  in,  743 
treatment  of,  743 
Height  in  childhood,  table  of,  242 

table  of,  242 
Hemartlirosis,  295  •       .    r 

of  knee-joint,   diagnosis  ot,   from 
tuberculosis,  419 
Hemiplegia    in    cerebral    paralysis    ot 

childhood,  treatment  of,  646 
Hemophilia,  294 

treatment  of,  295 
Hemorrhage  into  joints,  294,  290 
Hereditary  ataxia,  654 
Hernia,  diagnosis  of,  from  tuberculous 
i      disease  of  spine,  47 
'  High  shoe  in  treatment  of  tuberculous 
\      disease  of  hip-joint,  341 
Hip,  arthritis  deformans  ot,  diagnosis 
'        '     of,  from  tuberculosis,  331 

disease,  305.     See  Tuberculous  dis- 
ease of  hip-joint, 
dislocation  of,  congenital,  diagno- 
sis of,  from  tuberculous 
disease  of  spine,  45 
genu  recurvatum  and,  449 
high,  in  lateral  curvature  of  spine, 

151 
hysterical,  657 

diagnosis  of,  657 
pain  in,  657 
muscles  of,  paralysis  of,  in  acute 
poUomyelitis,  treatment  of,  629 
snapping,  561 
splint,  Taylor's,  371 

convalescent,  374 
subluxation  of,  congenital,  561 
Hip-joint,  anchylosis  of,  treatment  ot, 
303 
arthritis  of,  acute  infectious,  400 


882 


INDEX 


Hip-joint,  arthritis  of,  acute  infectious, 
diagnosis  of,  from 
congenital  disloca- 
tion, 539 
symptoms  of,  400 
treatment  of,  400 
deformans  of,  404 
congenital  dislocation  at,  diagnosis 

of,  from  tuberculosis,  333 
disease  of,  bilateral,  377 

treatment  of,  378 
double,  376 

with  tuberculosis  of  spine,  378 
dislocation  at,  congenital,  529 
acetabulum  in,  531 
anterior,  537 
arthrotomy  in,  555 
bilateral,  535 
capsule  in,  531 
diagnosis  of,  538 

from  bow-legs,  539 
from  coxa  vara,  539 
from    infectious    ar- 
thritis, 539 
epiphysitis,  539 
from  progressive 
muscular  dystro- 
phy, 539 
from  tuberculous  dis- 
ease of  spine,  539 
etiology  of,  533 
femur  in,  532 
Hoffa-Lorenz  operation 

for,  556 
in  infancy,  treatment  of, 

549 
ligamentum  teres  in,  531 
limp  in,  535 

Lorenz  operation  for,  540 
reduction  in,  541 
in   two  sit- 
tings, 544 
in     young 
subjects, 
544 
traction  in,  543 
muscles  in,  533 
in   older  subjects,   treat- 
ment of,  553 
open  operation  with  en- 
largement of  acetabu- 
lum in,  556 
osteotomy  in,  555 
pain  in,  536 
pathologj^  of,  530 
pelvis  in,  532 
prognosis  of,  552 
sailor  gait  in,  536 
statistics  of,  529 
supracotyloid,  538 
symptoms  of,  534 

general,  536 
treatment  of,  540 
palliative,  561 


Hip-joint,    dislocation  at,    congenital, 
treatment   of,    re- 
view of,  558 
variations  in,  549 
unilateral,  535 
waddle  in,  536 
epiphysitis  at,  acute,  400 

infectious,  diagnosis  of,  from 
congenital   dislocation, 
539 
symptoms  of,  400 
treatment  of,  400 
extra-articular  disease  of,  402 
gluteal  bursitis  of,  403 

treatment  of,  403 
gonorrheal  arthritis  of,  401 

diagnosis  of,  from  tuber- 
culosis, 331 
iliopsoas  biu-sitis  of,  403 

treatment  of,  403 
infectious  arthritis  of,  diagnosis  of, 

from  tuberculosis,  331 
mahgnant  disease  about,  403 
non-tuberculous  affections  of,  399 
osteo-arthi'itis  of,  404 
pain  in,  406 
symptoms  of,  406 
treatment  of,  406 
operative,  406 
range  of  motion  at,  Fig.  238,  305 
spontaneous  dislocation  of,  401 

treatment  of,  402 
subacute  arthritis  of,  401 
traumatisms  at,  399 

treatment  of,  399 
tuberculous  disease  of,  305 
abscess  in,  379 

significance  of,  381 
statistics  of,  379 
treatment  of,  381 
actual  lengthening  in,  325 

shortening  in,  322 
in  adults,  379 
age  in,  310 
apparent  lengthening  in,  312 

shortening  in,  314 
Ashley's  details  of  1000  cases 

of,  335 
atrophy  in,  319 

causes  of,  319 
causing  equinus,  398 

genu  recurvatum,  398 
loiock-knee,  398 
lateral  curvatm-e,  398 
laxity  of  Kgaments,  398 
changes  in  contour  of  liip  in, 

319 
debility  in,  325 
deformity  in,  correction  of,  389 
diagnosis  of,  330 

from  anterior  pohomyeli- 

tis,  331 
from  arthritis  deformans 
of  hip,  332 


INDEX 


Hip-joint,    tuberculous,    diagnosis   of, 
from  congenital  disloca- 
tion of  hip,  333 
from  coxa  vara,  332 
from  disease  of  bursse,  332 
from  epiphyseal  fracture, 

333 
from  epiphysitis,  331 
from  extra-articular  dis- 
ease, 331 
from  fracture  of  neck  of 
femur  in  children,  333 
from  gonorrheal  arthritis, 
^331 

*  from  "growing  pains," 
330 
from  hysterical  joint,  333 
from  infectious  arthritis, 

331 
from  local  injury,  330 

irritation,  330 
from  pelvic  disease,  332 
from    Perthes's    disease, 

331 
from   prohferative    poly- 
arthritis, 336 
from  rheumatism,  331 
from    sacroiliac    disease, 

332 
from  scurvy,  331 
from  synovitis,  331 
from  traumatic  coxa  vara, 

333 
from  tuberculous  disease 

of  spine,  332 
x-rays  in,  333 
distortion  of  limb  in,  312 
estimation  of,  328 

of  atrophy  in,  330 
Kingsley's     method, 
329 
etiology  of,  309 
examination  in,  method  of,  325 

physical,  326 
fever  in,  325 
frequency  of,  309 
history  in,  325 
in  infancy,  379 
Konig's  statistics  of,  315 
limp  in,  311 
local  signs  of,  330 
measurements  in,  327 
mortality  in,  392 
muscular  spasm  in,  312 
night  cry  in,  311 
pain  in,  310 
pathology  of,  305 
physical  signs  in,  311 
prognosis  of,  392 
recording  case  of,  333 
reduction  of  deformity  in,  by 
traction  brace,  344 
by  weight  and  pul- 
ley, 344 


Hip-joint,    tuberculous,  retardation  of 
growth  in,  323 
DoUinger  on,  323 
Taylor  on,  324 
sex  in,  312 
side  affected  in,  310 
sinuses  in,  treatment  of,  383 
stiffness  in,  312 
symptoms  of,  310 

general,  325 
treatment  of,  336 

amputation  in,  388 
Bradford  brace  in,  343 
during  stage  of  recovery, 

373 
functional  results  of,  394 
high  shoe  in,  341 
Judson  brace  in,  342 
Lorenz  spica  in,  365 
mechanical,  337 
review  of,  370 
sphnting,  337 
stilting,  337 
traction,  337 
operative,  excision,  384 

exploratory,  383 
perineal  bands  in,  341 
plaster  supports  in,  359 
application  of,  363 
Taylor  hip  brace  in,  343 
Thomas's,  354 

modification  of,  359 
traction  hip  splint  in,  338 
application  of,  341 
efficiency  of,  349 
lateral,  347 
plasters  in,  339 
Hoffa-Lorenz   operation  for  congenital 

dislocation  at  hip-joint,  556 
Hollow  foot,  728.    See  Foot,  contracted. 

round  back,  229 
Horizontal    fixation    in    treatment    of 

tuberculous  disease  of  spine,  63 
Housemaid's  knee,  444 
Hyperplasia  of  knee-joint,  444 

of  fatty  tissue  within  joint,  444 
symptoms  of,  444 
treatment  of,  444 
Hypertrophic  arthritis,  283 
etiology  of,  285 
pain  in,  287 
pathology  of,  283 
symptoms  of,  287 
treatment  of,  287 
osteo-arthropathy,  secondary,  527 
Hypertrophy  of  bone,  248 

of  feet,  congenital,  819 
Hysterical  joint  affections  and  deformi- 
ties, 654 
diagnosis  of,  from  tuberculo- 
sis, 333 
hip,  657 

diagnosis  of,  657 
pain  in,  657 


884 


INDEX 


Hj'sterical  knee-jerk,  diagnosis  of,  from 
tuberculosis,  419 
scoliosis,  657 
spine,  656 

sjTnptoms  of,  656 
talipes,  658 

treatment  of,  658 


Idiopathic  osteopsathyrosis,  522 
Iliopsoas  bm-sitis  of  hip-joint,  403 

treatment  of,  403 
Infantile  scorbutus,  516 

pathologj'  of,  516 
symptoms  of,  516 
treatment  of,  516 
tahpes,  treatment  of,  777 
Ingrown  toe-nail,  756 
Infectious  arthi-itis  of  ankle-joint,  diag- 
nosis of,  from  tuberculosis. 
461 
hip-joint,   diagnosis  of,   from 
congenital  disloca- 
tion, 539 
from       tuberculosis, 
331 
of    knee-joint,    diagnosis    of, 
from  tuberculosis,  419 
diseases,  arthritis  and.  277 
treatment  of,  277 
epiphysitis  of  hip-joint,  diagnosis 
of,  from  congenital  dislocation, 
539 
Inflammation   of   subdeltoid   biu-sa   in 

periarthritis  of  shoulder,  485 
lu-knee,  589 
Intermittent  hmp,  745 
Intervertebral  disks,  34 
Inverted  foot,  764 

Ischemic  paralysis  and  contraction,  507 
pain  in,  507 
swelling  in,  507 
S3'mptoms  of,  507 
treatment  of,  508 
corrective,  508 
operative,  508 
prevention,  508 


Jerking  fingers,  505 

Joint  affections,  hysterical,  654 

diagnosis  of,  from  tuberculosis, 
333 
Joints,  anchylosis  of,  299 
etiology  of,  299 
pathology  of,  299 
prevention  of,  299 
treatment  of,  299 

arthroplasty  in,  302 
forcible  correction  in,  300 


Joints,    anchylosis   of,    treatment    of, 
operative     exploration 
in,  302 
passive  niotion  in,  299 
Charcot's  disease  of,  295 
cUagnosis  of,  298 

from       tuberculosis, 
419 
distribution  of,  298 
pathologj'  of,  296 
s^^nptoms  of,  297 
treatment  of,  298 
diseases  of,  diagnosis  of,  from  acute 

anterior  pohomj'elitis,  615 
hemorrhage  into,  294,  295 
neurotic,  658 

etiology  of,  658 
symptoms  of,  659 
treatment  of,  659 
non-tuberculous  disease  of,  270 
syphilis  of,  270 

congenital,  271 
hereditary,  271 
treatment  of,  274 
tuberculous  disease  of,  249 
abscess  in,  255 
age  in,  253 

arborescent  syno\'ial,  258 
diagnosis  of,  262 

.r-rays  in,  262 
distribution  of,  252 
diy  caries  in,  259 
etiologv  of,  249 
latent, '249 

mode  of  infection  in,  249 
pathology  of,  254 
perforation  in,  256 
predisposition  to,  249,  251 
prognosis  of,  260 
repair  in,  259 
rice  bodies  in,  258 
septic  infection  in,  259 
sex  in,  253 
side  affected  in,  253 
treatment  of,  262 

active  congestion  in,  268 
Bier's  hji^eremia,  266 
Calot's  fluids  in,  265 
di'ugs  in,  264 
iodoform  in,  265 
mechanical,  264 
operative,  264 
passive  congestion  in,  267 
sunhght  in,  262 
.r-raj's  in,  266 
Judson  brace  in  treatment  of  acquired 
talipes  calcaneus,  836 
of   acute   anterior   poUo- 

myelitis,  627 
of  infantile  talipes,  781 
of  neglected  tahpes,  809 
of  paralj'tic  tahpes,  836 
of  tuberculous  disease  of 
liip-joint,  342 


INDEX 


885 


Judson  perineal  crutch,  373 
Jury-mast  in  treatment  of  tuberculous 
disease  of  spine,  74 


K 


•Keel-shaped  chest,  239 
Kingsley's  method  of  estimation  flex- 
ion  in   tuberculous   disease  of  hip- 
joint,  329 
Knee,  back,  446.     See  Genu  recurva- 
tum. 
bak^'s,  586 

contraction  of,  congenital,  454 
prognosis  of,  454 
treatment  of,  454 
dislocation  of,  congenital,  454 
housemaid's,  444 
snapping,  454 

treatment  of,  454 
Knee-joint,  anchylosis  of,  treatment  of, 
303 
arthritis    deformans    of,   diagnosis 

of,  from  tuberculosis,  419 
in  childhood,  injury  of,  437 
muscular  cramp  of,  437 
deformities  of,  437 
hemarthrosis  of,  diagnosis  of,  from 

tuberculosis,  419 
hyperplasia  of,  444 

of  fatty  tissue  within  joint,  444 
symptoms  of,  444 
treatment  of,  444 
hysterical,  diagnosis  of,  from  tuber- 
culosis, 419 
infectious  arthritis  of,  diagnosis  of, 

from  tuberculosis,  419 
internal  derangement  of,  439 
loose  bodies  in,  440 
non-tuberculous  affections  of,  437 
"quiet  effusion"  at,  439 
range  of  motion  at,  Fig.  324,  410 
rheumatism  of,  diagnosis  of,  froln 

tuberculosis,  419 
sarcoma  of,  diagnosis  of,  from  tu- 
berculosis, 419 
synovitis  of,  437 
acute,  437 

treatment  of,  437 
chronic,  438 

diagnosis  of,  from  tuberculo- 
sis, 419 
incidental,  439 
painless,  439 
recurrent,  438 
syphihs  of,  diagnosis  of,  from  tu- 
berculosis, 419 
tuberciilous  disease  of,  410 
abscess  in,  428 
actual  lengthening  in,  418 

shortening  in,  418 
age  in,  413 
causes  of  death  in,  435 


Knee-joint,  tuberculous,  complications 
of,  428 
deformities  in,  secondary,  415 
deformity  in,  reduction  of,  420 
diagnosis  of,  418 

from  arthritis  deformans, 

419 
from    Charcot's    disease, 

419 
from  hemarthrosis,  419 
from  hysterical  joint,  419 
from  infectious  arthritis, 

419 
from  injury  of  knee,  418 
from  rheumatism,  419 
from  sarcoma,  419 
from  synovitis,  419 
from  syphihs,  419 
distortions  in,  414 
etiology  of,  413 
extra-articular  disease  and, 

428 
knock-knee  and,  416 
limitation  of  motion  in,  414 
limp  in,  414 
mortahty  in,  434 
occurrence  of,  413 
pain  in,  414 
pathology  of,  410 
prognosis  of  deformity  in,  434 
rotation  of  tibia  upon  femur 

and,  415 
subluxation  of  tibia  and,  415 
symptoms  of,  413 
synonyms  of,  410 
synovial,  429 
treatment  of,  420 
accessory,  427 
amputation  in,  432 
arthrectomy  in,  430 
Bier's,  427 

Billroth  splint  in,  422 
cahper  brace  in,  426 
during  convalescence,  428 
excision  in,  431 

results  of,  432 
forcible  correction  by  re- 
verse leverage,  421 
functional  results  of,  434 
ichthyol  ointment  in,  427 
mechanical,  423 
operative,  430 

for  relief  of  final  de- 
formity, 432 
passive  congestion  in,  427 
plaster  splint  in,  420 
Thomas    brace    in,    423, 

424 
traction  in,  421 
x-rays  in,  427 
Knight  brace  in  treatment  of  genu  var- 
um, 605 
Knock-knee,  583,  589 
adolescent,  590 


880 


INDEX 


Knock-knee,   attitude  in,   accommoda- 
tive, 591 
of  rest  in,  585 
changed  relation  of  femur  and  tiljia 

in,  591 
deformitj^  in,  outgrowth  of,  586 
predisposition  to,  58-1 
secondarj",  591 
etiology  of,  583 
gait  in,  592 
measurements  in,  593 
onset  of,  584 
pathology  of,  594 
statistics  of,  583 
sjrmptoms  of,  590 
treatment  of,  595 
braces  in,  596 

duration  of,  599 
Thomas's,  596 
cuneiform  osteotomy  in,  600 
exercise  in,  596 
expectant,  595 
manipulation  in,  596 
operative,  599 
osteoclasis  in,  601 
osteotomy  in,  599 
posture  in,  596 
Wolff's.  601 
tuberculous    disease    of    hip-joint 
and,  398 
of  knee-joint  and,  416 
unilateral,  592 

with  bow-legs  and  general  rhachi- 
tic  distortions,  599 
Konig's  statistics  of  tuberculous   dis- 
ease of  hip-joint,  315 
Kohler's  chsease,  465 
Ki'ogius's  operation  for  sUpping  patella, 

452 
Kj-phosis,  229 

of  adolescents,  131 
postm-al,  230 
in  rhacliitis,  512 
symptoms  of,  231 
treatment  of,  231 


Lamixectoiiy  in  treatment  of  tubercu- 
lous disease  of  spine.  111 
"Late  rickets,"  515 
Lateral  curvature  of  spine,   144.     See 

Spine,  lateral  cm-vature  of. 
Leg,  muscles  of,  paralysis  of,  in  acute 
anterior  pohomyehtis,  treatment  of, 
625,  626 
Legs,  deformity  of,  weak  foot  in  child- 
hood and,  708 
Ligaments    of    patella,    elongation  of, 
453 
etiology  of,  453 
sj'mptoms  of,  453 
treatment  of,  453 


Ligamentum  teres  in  congenital  dislo- 
cation at  hip-joint,  531 
Limitation  of   motion  in    weak  foot, 

704 
Limp  in  congenital  dislocation  at  hip- 
joint,  535 
in  coxa  vara,  567 
intermittent,  745 
in   tuberculous   disease   of  ankle- 
joint,  458 
of  liip-joint,  311 
of  knee-joint,  414 
Loose  bodies  in  knee-joint,  440 
Lordosis,  233 

treatment  of,  233 
tuberculous    disease    of    hip-joint 
and,  398 
Lorenz  apparatus  in  treatment  of  tuber- 
culous disease  of  spine,  63 
operation  for   congenital  disloca- 
tion   of     hip, 
540 
reduction  in,  541 
in  two  sit- 
tings, 544 
in  young 
subjects, 
544 
traction  in,  543 
spica  in  treatment  of  tuberculous 
disease  of  hip-joint,  365 
Lumbago,  diagnosis  of,  from  tubercu- 
lous disease  of  spine,  43 
Luxation  of  clavicle,  acquired,  240 
treatment  of,  241 


M 


Malformatiox  of  pectoral  muscles,238 

of  vertebrae,  236 
Mahgnant  disease  about  hip-joint,  403 
of  bone,  304 
of  spine,  119 
Malleotomy  in  treatment  of  neglected 

tahpes,  796 
MaUet-finger,  506 

treatment  of,  506 
Measm'ements,  table  of,  327 
Meningitis,  cerebrospinal,  diagnosis  of, 
from   tuberculous  disease  of   spine, 
60 
Metatarsal  arch,   anterior,   depression 
of,  732 
weakness  of,  732 
bones,  fracture  of,  757 

treatment  of,  757 
Metatarsalgia,  anterior,  732 
etiology  of,  733 
gout  and,  737 
herechty  in,  737 
influence  of  shoe  in  causing 

disabihty  and  pain,  736 
pathology  of,  733 


Index 


887 


Metatarsalgia,    anterior,    rheumatism 
and,  737 
treatment  of,  738 
Metatarsus  varus,  750 
Military  orthopedics,  859 
Molhtes  ossium,  523 
Motion  at  joints,  range  of,  ankle  and 
foot,  702 
hip,  Fig.  238,  305 
knee.  Fig.  324,  410 
shoulder,  Fig.  361,  473 
spine,    atlo-axoid   articu- 
lation, 55 
Morbus   coxse,  305.     See  Tuberculous 

disease  of  hip-joint. 
Morton's  neuralgia,  732 
etiology  of,  733 
gout  and,  737 
heredity  and,  737 
influence  of  shoe  in  causing 

disability  and  pain,  736 
pathology  of,  733 
rheumatism  and,  737 
treatment  of,  738 
Multiple  myeloma  of  bone,  522 

neuritis,  diagnosis  of,  from  acute 
anterior  poliomyelitis,  615 
Muscle-building    exercises    in    lateral 

curvature  of  spine,  200 
Muscles  of  arm,  paralysis  of,  in  acute 
anterior  poliomyelitis,  treatment 
of,  631  . 

in  congenital  dislocation  at  hip- 
joint,  533 
of  foot,  function  of,  689 
of  hip,  paralysis  of,  in  acute  ante- 
rior poUomyelitis,  treatment  of, 
629 
of  leg,  paralysis  of,  in  acute  ante- 
rior poliomyelitis,  treatment  of. 
625,  626 
pectoral,  malformation  of,  238 
of   thigh,    paralysis   of,    in    acute 
anterior  poliomyelitis,  treatment 
of,  626 
Muscular  atrophy,  progressive,  651 
cramp  of  knee-joint  in  childhood, 

437 
dystrophy,  652 

diagnosis  of,  from  tuberculous 
disease  of  spine,  45 
paralysis,  pseudohypertrophic,  653 
diagnosis  of,  653 
treatment  of,  653 
spasm   in  tuberculous  disease  of 
hip-joint,  312 
of  spine,  50 
in  weak  foot,  704 
Myelitis,  transverse,  diagnosis  of,  from 

acute   anterior   poliomyelitis,    615 
Myeloma  of  bone,  multiple,  522 
Myelopathic  atrophy,  651 

paralysis,  651 
Myopathic  paralysis,  652 


N 


Napier  brace  in   treatment  of   genu 

varum,  605 
Neck,  deformities  of,  in  acute  anterior 
poliomyelitis,  620 
of  femur,  depression  of,  562 
Neglected     club-foot,     treatment    of 
788 
talipes,  treatment  of,  788 
Nekton's  hne,  relation  of,  565 
Nerve  drafting  in  treatment  of  acute 

anterior  poliomyelitis,  639 
Nervous  system,  diseases  of,  610 
Neuralgia,  Morton's,  732 
etiology  of,  733 
gout  and,  737 
heredity  and,  737 
influence  of  shoe  in  causing 

disability  and  pain,  736 
pathology  of,  733 
rheumatism  and,  737 
treatment  of,  738 
plantar,  744 

pain  in,  744 
treatment  of,  744 
Neuritis,  654 

multiple,  diagnosis  of,  from  acute 

anterior  poliomyelitis,  615 
of  spine,  138 
Neuroses,  vasomotor  trophic,  of  foot, 

•744 
Neurotic  joints,  658 

etiology  of,  658 
symptoms  of,  659 
treatment  of,  659 
spine,  655 

pain  in,  655 
sensitiveness  in,  655 
symptoms  of,  655 
treatment  of,  656 
Night   cry  in   tuberculous   disease   of 
hip- joint,  311 
of  spine,  27 
Non-tuberculous     affections     of     hip- 
joint,  399 
of  knee-joint,  437 
of  spine,  119 
disease  of  joints,  270 


Obstetrical  injury  to  brachial  plexus, 
repair  of,  495 
paralysis,  489 

deformity     in,    reduction    of, 

491 
diagnosis  of,  from  acute  ante- 
rior poliomyehtis,  616 
treatment  of,  491 
Ocular  torticoUis,  679 
Opisthotonos,  cervical,  678 


888 


INDEX 


Osteitis 


deformans,  524 
local,  527 
of  spine,  132 
treatment  of,  526, 


.T-ra5's 


hyper- 
juvenilis, 
409 


fibrosa,  404,  520 

diagnosis        of, 
521 
Osteo-arthritis,  283 
of  hip-joint,  404 
pain  in,  406 
symptoms  of,  406 
treatment  of,  406 
operative,  406 
of  spine,  124,  128 
Osteo-arthropathy,    secondary 

trophic,  527 
Osteochondritis    deformans 
407 
treatment   of, 
dessicans,  443 

diagnosis    of,    443 
etiology'  of,  443 
symptoms  of,  443 
treatment  of,  443 
x-raj^s  in,  443 
syphilitic,  270 
Osteochondromatosis,  444 
Osteoclasis  in  treatment   of  bow-legs, 
606 
of  genu  valgmii.  601 

varum,  606 
of  knock-knee,  601 
of      neglected      talipes,    801, 
802 
Osteoclast,  Grattan's,  601 
Osteogenesis  imperfecta,  522 
Osteomalacia,  523 
in  childhood,  523 

treatment  of.  523 
local,  523 
Osteomyelitis,  acute,  279 
prognosis  of,  282 
of  spine,  120 

sjTnptoms  of,  120 
treatment  of.  121 
symptoms  of,  280 
treatment  of,  280 
chronic,  282 

treatment  of,  282 
Osteopsath}Tosis,  idiopatliic,  522 
Osteotomy  in  congenital  dislocation  at 
hip-joint,  555 
for  coxa  vara,  572,  573 
cimeiform,    in    treatment    of    ne- 
glected tahpes,  806 
secondare',    in    treatment    of    ne- 
glected talipes,  808 
in    treatment    of    acute    anterior 
poliomyelitis,  639 
of  genu  valgum.  599 

varmn,  606 
of  knock-knee,  599 
Overlapping  toes,  756 

treatment  of,  756 


Paix  in  achillobursitis,  741 
in  back,  135 

treatment  of,  136 
in   congenital  dislocation  at  hip- 
joint,  536 
in  degenerative  arthritis,  287 
in  displacement  of  semilunar  car- 
tilage, 440 
in  hjqjertrophic  arthi'itis,  283 
in  hysterical  hip,  657 
in  ischemic     parah'sis     anrl     con- 
traction, 508 
in  neurotic  spine,  655 
in  painful  heel,  743 
in  periarthritis  of  shoulder,  485 
in  plantar  neuralgia,  744 
in  posterior  achillobm'sitis,  742 
in  sacro-ihac  disease,  139 
in  sprain  of  ankle-joint,  466 

of  wrist-joint.  487 
in   tuberculous   disease   of   elbow- 
joint,  478 
of  hip-joint,  310 
of  knee-joint,  414 
of  shoulder-joint,  475 
of  spine,  27,  38,  39,  50,  53 
of  -m-ist-joint,  482 
Painful  gi-eat  toe,  746 

in  older  subjects,  747 
heel,  743 

treatment  of,  743 
shoulder,  484 
warts,  740 
Paralvsis  in   acute   anterior   poliomve- 
litis,  612 
effect  of,  617 
Aran-Duchenne  tA'pe  of,   651 
Charcot-Marie-Tooth      tvpe     of, 

651 
of  childhood  cerebral,   641 
acquired,  641 

after-birth,  642 
during  labor,  642 
intra-uterine,  641 
deformities  in,  645 
disability'  in,  646 
loss  of  gro'wth  in,  646 
congenital,  641 

deformities  in,  644 
mentality  in,  645 
weakness  in,  643 
diagnosis  of,  from  acute 
anterior    polio mvelitis, 
615 
distribution  of,  641 
etiology  of,  641 
pathology  of,  641 
prognosis  of,  650 
symptoms  of,  642 
mental,  642 
motor,  642 
treatment  of,  646 


INDEX 


889 


Paralysis  of  childhood  cerebral,  treat- 
ment   of,    decom- 
pression of    brain 
in,  650 
of  hemiplegia,  646 
muscle    transplanta- 
tion in,  647 
operative,  649 
of  paraplegia,  648 
diphtheritic,    diagnosis    of,    from 
acute    anterior    polio- 
myelitis, 616 
from  tuberculous  diseases 
'^        of  spine,  60 
torticollis  and,  678 
of  muscles  of  arm  in  acute  anterior 
poliomyelitis,  treatment  of, 
631 
of  hip  in  acute  anterior  polio- 
myelitis, treatment  of,  629 
of  leg  in  acute  anterior  polio- 
myelitis, treatment  of,  625 
of    thigh    in    acute    anterior 
poliomyelitis,  treatment  of, 
626 
myelopathic,  651 
myopathic,  652 
obstetrical,  489 

deformity    in,    reduction    of, 

491 
diagnosis  of,  from  acute  ante- 
rior poliomyelitis,  616 
treatment  of,  491 
pseudohypertrophic  muscular,  653 
diagnosis  of,  653 
treatment  of,  653 
spastic,  641.    See  Cerebral  paraly- 
sis of  childhood, 
diagnosis   of,    from    tubercu- 
lous disease  of  spine,  60 
spinal,  651 
in  tuberculous  disease  of  spine,  29 
Paralytic    scoliosis    in    acute    anterior 
poliomyelitis,  treatment  of,  631 
talipes,  834 

deformity  in,  development  of, 

834 
etiology  of,  834 
symptoms  of,  834 
treatment  of,  835 

arthrodesis  in,  839 
astragalectomy  in,  839 
backward     displacement 

in,  839 
Judson  brace  in,  836 
operative,  838 
silk  ligaments  in,  839 
tendon  fixation  in,  839 
transplantation  in, 
839 
Whitman's  operation  for,  839 
Willett's    operation   for,    838 
torticollis,  678 
Paraplegia,  ataxic,  654 


Paraplegia    in    cerebral    paralysis    of 
childhood,  treatment  of,  648 
Pott's,  105 

diagnosis  of,  from  acute  ante- 
rior poliomyelitis,  615 
primary  spastic  spinal,   diagnosis 

of,  from  tuberculosis,  60 
spastic  spinal,   diagnosis  of,  from 
acute  anterior  poliomyelitis,  615 
Patella,  absence  of,  450 

treatment  of,  450 
acquired  displacement  of,  450 
congenital  displacement  of,  450 
ligaments  of,  elongation  of,  453 
etiology  of,  453 
symptoms  of,  453 
treatment  of,  453 
rudimentary,  450 

treatment  of,  450 
slipping,  450 

etiology  of,  450 
symptoms  of,  451 
treatment  of,  451 

Krogius's   operation    for, 

452 
operative,  452 
Pectoral  muscles,  malformation  of,  238 
Pectus  cavinatum,  239 

excavatum,  239 
Pelvic  abscess,  diagnosis  of,  from  tuber- 
culous disease  of  spine,  46 
in  tuberculous  disease  of  spine, 
40 
Pelvis  in  congenital  dislocation  at  hip- 
joint,  532 
diseases    of,    diagnosis    of,    from 
tuberculous  disease  of  hip-joint, 
332 
inclination  of,  34 
Periarthritis  of  shoulder,  484 

inflammation    of    subdeltoid 

bursa  in,  485 
pain  in,  485 
symptoms  of,  485 
treatment  of,  486 
operative,  487 
Perineal  band  in  tuberculous  disease  of 
hip-joint,  341 
crutch,  Judson' s,  373 
Perinephritic     abscess,     diagnosis     of, 
from  tuberculous  disease  of  spine,  46 
Peronei  tendons,  displacement  of,  758 

treatment  of,  758 
Perthes'  disease,  407 

diagnosis    of,    from    tubercu- 
lous disease  of  hip-joint,  331 
Pes  planus,  705 

Phalanges   of   fingers,    congenital   dis- 
placement of,  505 
Phelps'  bed  in  treatment  of  tubercu- 
lous disease  of  spine,  63 
operation  in  treatment  of  neglected 
talipes,  803 
Pigeon  breast  in  rhachitis,  511 


890 


INDEX 


Pigeon  chest,  239 

treatineut  of,  239 
in  tuberculous  disease  of  spine,  1 
49 
toe,  749 
Plantalgia,  744 
Plantar  flexed  foot,  764 
neuralgia,  744 
pain  in,  744 
treatment  of,  744 
Plaster  bandages  in  treatment   of  in- 
fantile talipes,  778 
cast  in  treatment  of  weak  foot,  713 
jacket    in  treatment    of   tubercu- 
lous disease  of  spine,  70 
splint  in  treatment  of  tuberculous 

disease  of  knee-joint.  420 
strapping   in   treatment    of   rigid 
weak  foot,  724 
of  sprain  of  ankle-joint, 
466 
supports  in  treatment  of  tubercu- 
lous disease  of  liip-joint,  359 
Pleuris}',   diagnosis  of,   from  tubercu- 
lous disease  of  spine,  52 
Pneumonia,   diagnosis  of,  from  tuber- 
culous disease  of  spine,  52 
Poliomyelitis,  acute  anterior,   610 
age  in,  611 

deformities   in     of    neck, 
620 
secondary,  622 
of  trunk,'  620 
of  upper  extremity, 
620 
deformity  in.  cause  of,  617 
fimctional      use 
as,  619 
reduction   of,    632 
diagnosis    of,    614 

from     diphtheritic 

paralj'sis,  616 
from   joint    diseases, 

615 
from   multiple    neu- 
ritis, 615 
from  obstetrical  par- 
alysis, 616 
from    paralysis    of 
cerebral   origin   in 
cliildhood,  615 
from     Pott's     para- 
plegia, 615 
from    pseudoparaly- 
sis, 616 
from  rheumatism,  615 
from    spastic    spinal 

paraplegia,    615 
from  transyerse  mye- 
litis, 615 
from  tuberculous  dis- 
ease   of    hip-joint, 
331 
from  weakness,   616 


Poliomyelitis,    acute    anterior,    distor- 
tions in,  compensatory, 
623 
electrical  test  in,  616 
muscle  and  tendon  trans- 
plantation in,  635 
muscular     action    and 

gi-a\'ity  in,  618 
onset  of,  613 

paralysis  of  deltoid  mus- 
cle in,    transplan- 
tation of  trapezius 
for,  635 
distribution   of,    612 
effect  of,  617 
of  muscles  of  arm  in, 
treatment  of, 
631 
of  hip  in,  treat- 
ment of,  629 
of  leg  in,  treat- 
ment of,  625, 
626 
of  tliigh  in  treat- 
ment of,  626 
paralytic    scoliosis    in, 

treatment  of,  631 
postm-e  in,  619 
prognosis  of,  116 
retardation     of     growth 

in,  623 
season  in,  611 
subluxation  in,  620 
sjTnptoms  of,  613 
transplantation   of   ham- 
string muscles  in, 
639 
of  trapezius  in,  635 
treatment  of,  624 

artkrodesis  in,  639 
muscle    training    in, 
632 
'  nerye    grafting   in, 
639 
operatiye,  632 
osteotomy  in,  639 
reA'iew  of,  639 
silk  ligaments  in,  638 
Thomas  cahper  brace 
in,  634 
knock-knee  brace 
in,  634 
Polyarthritis,    proltferatiye,    diagnosis 
of,  from  tuberculous  disease  of 
hip-joint,  332 
StiU's,-289 
Popliteal  region,  bursae  in,  446 

cysts  in,  446 
Posterior  achillobursitis,  742 
Postural  equinus,  728 

kyphosis,  230 
Postm-e  in  acute  anterior  poliomyehtis, 

619 
Pot  belh-  in  rhachitis,  511 


INDEX 


891 


Pott's  disease,    17.     See  Tuberculous 
disease  of  spine, 
paraplegia,  105 

diagnosis  of,  from  acute  ante- 
rior poliomyelitis,  615 
Prepatellar  biu'sitis,  444 

treatment  of,  444 
Pretibial    bm-sa,    superficial,    enlarge- 
ment of,  445 
bursitis,  445 

symptoms  of,  445 

treatment  of,  445 

Progressive  muscular  atrophy,  651 

Proliferating  arthritis,  287 

etiology  of,  290 

treatment  of,  290 

ProUferative  arthritis,  283 

polyarthiitis,    diagnosis   of,    from 
tuberculous  disease  of  hip-joint, 
332 
Pronated  foot,  693 
Pronation  of  forearm,  congenital,  498 

treatment  of,  498 
Pseudohyperthrophic     muscular    dys- 
trophy, diagnosis  of,  from 
tuberculous  disease  of  spine, 
59 
paralysis,  653 

diagnosis  of,  653 
treatment  of,  653 
Pseudoparalysis,    diagnosis    of,    from 
acute  anterior  poliomyelitis,  616 
in  rhachitis,  514 
Psoas  contraction  in  tuberculous  dis- 
ease of  spine,  38 
Psychical  torticolhs,  679 
Puerperal  arthritis,  276 


"Quiet  effusion"  at  knee-joint,  439 


B 


Radius    displacement    of,    congenital, 

498 
Range  of  motion  at  joints,  ankle  and 
foot,  702 
hip,  Fig.  238,  305 
knee.  Fig.  324,  410 
shoulder.  Fig.  361,  473 
spine,   atlo-axoid   articu- 
lation, 55 
Raynaud's  disease  of  foot,  745 
Reciu'rent  dislocation  of  shoulder,  497 
treatment  of,  497 
operative,  497 
synovitis  of  knee-joint,  438 
Respiration  in  tuberculous  disease  of 

spine,  50 
Retardation  of  gi'owth  in  acute  ante- 
rior poliomyelitis,  623 


Retrocalcaneobursitis,  740 
Rhachitic  kyphosis,  132 

lateral  curvature  of  the  spine,  163 
rosary  in  rhachitis,  510 
torticolhs,  679 
spine,  131 

attitude  in,  132 
natural  cure  of,  132 
treatment  of,  131 
Rhachitis,  509 

acute,  diagnosis  of,  from  tubercu- 
lous disease  of  spine,  47 
age  of  onset  in,  509 
attitude  in,  512 
caput  quadratum  in,  511 
craniotabes  in,  511 
cubitus  valgus  in,  512 

varus  in,  512 
deformities  in,  510 
distortions  of  lower  limb,  609 
double  joints  in,  511 
etiology  of,  509 
Harrison's  groove  in,  511 
kyphosis  in,  512 
pathology  of,  509 
pigeon  breast  in,  511 
pot  belly  in,  511 
prognosis  of,  514 
pseudoparalysis  in,  514 
rhachitic  rosary  in,  510 
scoliosis  in,  512 
symptoms  of,  510 
treatment  of,  515 
Rheumatism,  294 

anterior  metatarsalgia  and,  737 
diagnosis  of,  from  acute  anterior 
poliomyelitis,  615 
from    tuberculous    disease  of 
ankle-joint,  461 
of  hip-joint,  331 
of  knee-joint,  419 
gonorrheal,  274 
Morton's  neuralgia  and,  737 
tuberculous,  294 
l!lheumatoid  arthritis,  283 

of  spine,  127 
Ribs,  abnormalities  of,  236 
absence  of,  237 
cervical,  236 
Rice  bodies  in  tuberculous  disease  of 

joints,  258 
Rickets,  509.    See  Rhachitis. 
late,  515 

scurvy,   516.     See  Infantile  scor- 
butus. 
Rigid  weak  foot,  718 

treatment  of,  718 
adjuncts  in,  724 
manipulation  in,  721 
overcorrection  in,  forcible, 
719 
functional  use  in,  720 
plaster  strapping,  724 
Thomas's,  724 


892 


INDEX 


Rigid  weak  foot,  varieties  of,  723 
Rotary  lateral  curvature,  144 
Rotation  in  lateral  curvature  of  spine, 

147 
Round  back,  228 

hollow,  229 
shoulders,  230 

diagnosis    of,    from    tubercu- 
lous disease  of  spine,  51 
Rudimentary  patella,  450 
treatment  of,  450 
Rupture  of  spinal  ligaments,  122 
Rydygier  incision  for  excision  of  hip  in 
tuberculosis,  385 


Sacro- ILIAC     articulation,     injury     or 
weakness  of,  141 
disease,  139 

abscess  in,  140 
diagnosis  of,  140 

from  tuberculous  disease 
of  hip-joint,    140, 
332 
of  spine,  45 
pain  in,  139 
prognosis  of,  140 
symptoms  of,  139 
treatment  of,  140 
Sarcoma  of  femur,  403 

of  knee-joint,   diagnosis   of,   from 
tuberculosis,  419 
Scapula,  congenital   elevation   of,   234 
etiology  of,  235 
treatment  of,  235 
Scapular  crepitus,  240 
Scapulohumeral  periarthritis,   484 
Scarlatina,  arthritis  and,  277 
Schlatter's  disease,  445 
Schultze    pelvic    support    for    plaster 
spica   in   treatment   of   tuberculous 
disease  of  hip-joint,  363 
Sciatic  scoliosis,  136 
Sciatica,  deformity  secondary  to,   136 
treatment  of,  138 
diagnosis  of,  from  tuberculous  dis- 
ease of  spine,  44 
Scoliosis  144.    See  Spine,  lateral  curva- 
ture of. 
hysterical,  657 

paralytic,  in  acute  anterior  polio- 
myelitis, treatment  of,  631 
in  rhachitis,  512 
sciatic,  136 
Scorbutus,  295 
infantile,  516 

pathology  of,  516 
symptoms  of,  516 
treatment  of,  516 
Scurvy,  295,  516 

diagnosis  of,  from  tuberculous  dis- 
ease of  hip-joint,  337 


Scurvy,  diagnosis  of,  from  tuberculous 
disease  of  spine,  47 
rickets,  516. 
Secondary  hypertrophic  osteo-arthrop- 

athy,  527 
Self-correction  exercises  in  lateral  cur- 
vature of  spine,  194 
Semilunar  cartilage,   displacement  of, 
440 
Campbell  brace  in,  442 
Griffith's  brace  in,  441 
pain  in,  440 
treatment  of,  441 
Septic  infection  in  tuberculous  disease 
of  bones,  259 
of  joints,  259 
Shoe,  high,  in  treatment  of  tuberculous 
disease  of  hip-joint,  341 
in  treatment  of  weak  foot,  710 
Shoes,  758 

flat  sole,  761 
for  normal  feet,  759 
for  shoemaker's  feet,  760 
hallux  valgus  and,  751 
rocker  sole,  761 
Shoulder,  dislocation  of,  congenital,  489 
recurrent,  497 

treatment  of,  497 
operative,  497 
high,  in  lateral  curvature  of  spine, 

151 
painful,  484 
periarthritis  of,  484 

inflammation    of    subdeltoid 

bursa  in,  485 
pain  in,  485 
symptoms  of,  485 
treatment  of,  486 
operative,  487 
stiff,  484 
Shoulder-joint,  bursitis  of,  chronic,  487 
range  of  motion  at.  Fig.  361,  473 
tuberculous  disease  of,  473 
age  in,  475 
atrophy  in,  475 
pain  in,  475 
pathology  of,  473 
prognosis  of,  477 
restriction  of  motion  in,  475 
sensitiveness  in,  475 
symptoms  of,  475 
treatment  of,  475 
Shoulders,  round,  230 
Silk  ligaments  in  treatment  of  talipes 
calcaneus,  839 
equinus,  828 
of   acute   anterior   polio- 
myelitis, 638 
of  paralytic  tahpes,  839 
Sinuses  in  tuberculous  disease  of  hip- 
joint,  383 
Slipping  patella,  450 

etiology  of,  450 
symptoms  of,  451 


INDEX 


893 


Slipping  patella,  treatment  of,  451 

Krogius's   operation   for, 

452 
operative,  452 
Snapping  finger,  505 
hip,  561 
knee,  454 

treatment  of,  454 
Socks,  762 

Spasm,  muscular,  in  tuberculous  dis- 
ease of  spine,  50 
Spasmodic  torticollis,  665,  673 
etiplogy  of,  674 
pathology  of,  674 
prognosis  of,  674 
treatment  of,  674 
operative,  675 
Spastic  paralysis,  641 

diagnosis  of,  from  tuberculous 
disease  of  spine,  60 
spinal  paralysis,  651 

diagnosis  of,  from  acute 
anterior    poliomyelitis, 
615 
paraplegia,  diagnosis  of,  from 
tuberculosis,  60 
Spina  bifida,  talipes  and,  819 
ventosa,  484 

treatment  of,  484 
Spinal  cord,  length  of,  34 

ligaments,  rupture  of,  122 
paralysis,  spastic,  651 

diagnosis  of,  from  acute 
anterior    poliomyelitis, 
615 
primary,     diagnosis     of, 
from  tuberculosis,  60 
Spine,  actinomycosis  of,  121 
arthritis  of,  124 

treatment  of,  124 
articulations    of,    infectious    dis- 
eases of,  123 
carcinoma  of,  119 

diagnosis  of,  120 
contour  of,  variations  in,  228 
coverings  of,  infectious  diseases  of, 

123 
deformities  of,  anteroposterior,  229 
deviation  of,  in  tuberculosis,  51 
divisions  of,  30 
fracture  of,  121 
hysterical,  656 

symptoms  of,  656 
injury  of,  treatment  of,  122 
kyphosis  of,  132 
landmarks  of,  33 
lateral  curvature  of,  144 
age  in,  152 
changes     in     anteroposterior 

contour  in,    149 
compensatory  deformity  and, 

159 
congenital,  162 
definition  of,  144 


Spine,  lateral  deformity  elsewhere  and, 
159 
prevention  of,  174 
varieties  of,  168 
description  of,  144 
deviation  in,  147 
diagnosis  of,  170 

mobility  in,  170 
posture  in,  170 
records  in,  171 
disease  within  thoracic  walls 

and,  160 
etiology  of,  156 
exercises  in   body   inclination 
to  left,  419 
chest  pressing  with  right 

hand,  195 
head  bending  backward, 

194 
horizontal  bar  puUups,  203 
left    hip    twisting    back- 
ward, 196 
leg  hopping,  204 
standing,  pelvis, 
tilting,  204 
neck  firm,  194 
oblique    stride, 
standing,   197 
muscle  building,  200 
opposite  bend    standing, 
trunk   raising,   re- 
sisted, 200 
sitting,       backward, 
bending  of  trunk, 
203 
standing,  head  bend- 
ing backward,  re- 
sisted, 200 
prone  lying,  diving,  203 
head  and  shoul- 
der      raising, 
the  seal,  201 
leg  raising,  203 
respiratory,  half -reclining, 
arm     extensions     and 
flexions,  resisted,  204 
right  neck  firm,   196 
self -correction,  194 
trunk    bending    forward, 
197 
hereditary  influence  in,  165 
high  hip  in,  151 

shoulder  in,  151 
incidental,  161 
occupation  and,  161,  166 
paralysis  and,  159 
pathology  of,  151 
prognosis  of,  172 
relative  frequency  of,  156 
rhachitic,  163 

treatment  of,  176 
rotation  in,  147 
sex  in,  156 
summary  in,  173 


894 


INDEX 


Spine,  lateral,  symptoms  of,  169 
synonyms  of,  14-4 
treatment  of,  175 
Abbott,  210 
corrective,  combined  mth 

support,  207 
dm-ation  of,  227 
exercises  in,  178,  179 

muscle  building,  200 
self -correction,  194 
general,  227 
high  shoe  in,  227 
posture  in,  178 
principles  of,  176 
self-suspension  in,  225 
removal   of    superincum- 
bent weight,  in,  224 
supplemental,  224 
support     dm-ing    recum- 
bency in,  227 
Volkmann  seat  in,  226 
tuberculous     disease     of 
hip-joint  and,  398 
mahgnant  disease  of,  119 
nemitis  of,  138 
neurotic,  655 
pain  in,  655 
♦  sensitiveness  in,  655 

sjonptoms  of,  655 
treatment  of,  656 
non-tuberculous  affections  of,  119 
osteitis  deformans  of,  132 
osteo-arthi'itis  of,  124,  128 
osteomyehtis  of,  acute,  120 
symptoms  of,  120 
treatment  of,  121 
range  of  motion  at,  55 
rhachitic,  131 

attitude  in,  132 
natural  cm-e  of,  132 
treatment  of,  131 
rhemnatism  of,  gonorrheal,  124 

treatment  of,  124 
rheumatoid  arthritis  of,  127 
rotary-lateral  curvature  of,  diag- 
nosis of,  from  tuberculosis,  52 
syphihs  of,  119 

diagnosis  of,  119 

tabetic  deformity  of,  133 

tuberculous  disease  of,  17 

abscess  in,  29,  98 

course    and   peculiarities 
of,  in  different  regions, 
100 
treatment  of,  101 
age  at  onset  of,  22 
attitude  in,  change  of,  27 
awkwardness  in,  27 
case  record  in,  60 
complications  of,  98 
contour  of  spine  in,  29 
change  of,  28 
deformity  in,  17,  28 
bone,  28 


Spine,     tuberculous,      deformity     in, 
compensatory,  28 
later  effects  of,  117 
muscular,  28 
secondary,  118 
losis    of,    from    cerebro- 
spinal meningitis,  60 
from    cervical      opistho- 
tonos, 58 
from   congenital  disloca- 
tion of  hip-joint,  539 
from  diphtheritic  paraly- 
sis, 60 
from    primary    spastic 
spinal  paraplegia,  60 
from  pseudohypertrophic 
muscular  dystrophy,  59 
from  spastic  paralysis,  60 
from  tuberculous  disease 

of  hip-joint,  332 
general,  59 

Roentgen-ray    photogra- 
phy in,  60 
etiolog}^  of,  21 

examination  in,  regional,  37 
flexibihty  of  spine  in,  29 
frequency  of,  21 
history  in,  34 
impahment    of    fmiction    in, 

27 
loss  of  mobiUty  in,  27 
in  lower   cervical  region,    55 
region,  37 

attitude  in,  37 
diagnosis  of,  43 

from  acute  rhachitis, 

47 
from  appendicitis,  46 
from   bilateral    con- 
genital dislocation 
of  hip,  45 
from  hernia,  47 
from  hip  disease,  45 
from  Imnbago,  43 
from  muscular  dys- 
trophies, 45 
from  pelvic  abscess, 

46 
from       perinephritic 

abscess,  49 
from  sacro-iliac  dis- 
ease, 45 
from  sciatica,  44 
from  scm'vy,  47 
from  spondyhtis  de- 
formans, 45 
from  spondylohsthe- 

sis,  45 
from  strain  of  back, 
43 
lateral    inchnation    of 

body  in,  38 
lordosis  in,  37 
pain  in,  38,  39 


INDEX 


895 


Spine,    tuberculous,    in  lower  cervical 
region,    peculiarities 
of,  in  infancy,  47 
pelvic  abscess  in,  43 
psoas  contraction  in,  38 
stiffness  in,  39 
stooping  in,  40 
symptoms  of,  summary 

of,  48 
treatment  of,  96 
weakness  in,  39 
in   middle   and   upper   dorsal 

region,  treatment  of,  97 
night  cry  in,  27 
in  occipito-axoid  region,  treat- 
ment of,  98 
pain  in,  27 

paralysis  in,  29,  105  * 
duration  of,  107 
frequency  of,  106 
laminectomy  in.  111 
liability   to,   in   different 

regions,  106 
local,  112 
prognosis  of,  109 
symptoms  of,  107 
time  of  onset  of,   107 
treatment  of,  110 
pathology  of,  18 
physical  signs  of,  35 
prognosis  of,  25 
rational  signs  of,  34 
recurrence  of,  117 
sex  in,  22 
situation  of,  23 
stiffness  in,  27 
symptoms  of,  26 

complicating,  29 
general,  29 
secondary,  29 
synonym  of,  17 
in  thoracic  region,   48 
abscess  in,  51 
attitudes  in,  48 
cough  in,  50 
deviation    of    spine    in, 

51 
diagnosis  of,  51 

from  empyema,  52 
from  pleurisy,  52 
from  pneumonia,  52 
from      rotary-lateral 

curvature,  52 
from  round    should- 
ers, 51 
muscular  spasm  in,  50 
pain  in,  50 
pigeon  chest  in,  49 
respiration  in,  50 
symptoms    of,    summary 
of,  53 
treatment  of,  61 

ambulatory  supports  in, 
70 


Spine,  tuberculous,  treatment  of,  Brad- 
ford bed  frame  in,  63 
Calot  jacket  in,  76 

application     of, 

80,  83 

comparison    of    the    two 

forms    of    ambulatory 

support  in,  92 

convex    stretcher    frame 

in,  63 
corset     in,     other     than 
plaster  of  Paris,  85 
plaster,  84 
duration  of,  116 
horizontal  fixation  in,  63 
jury-mast  in,  74 
Lorenz  apparatus  in,  63 
mechanical  principles  of, 

61 
operative,  112 
Phelps  bed  in,  63 
plaster  jacket  in,  70 
principles    of,     in     their 
practical     application, 
95 
by    recumbency,    indica- 
tions for,  95 
Taylor  back  brace  in,  85 
Thomas  collar  in,  93 
in   upper  dorsal  and  middle 
cervical   region,    treat- 
ment of,  98 
region,  53 

attitude  in,  53 
diagnosis  of,  56 
from  abscess,  59 
from  arthritis,  59 
from    cervical    opis- 
thotonos, 58 
from  injury,  58 
from  torticollis,  56 
pain  in,  53 
stiff  neck  in,  53 
symptoms  of,  53 

summary  of,  59 
weak  foot  and,  118 
weakness  in,  27 
tumors  of,  119 
typhoid,  123 

diagnosis  of,  123 
treatment  of,  123 
Splay-foot,  693 
Splint,  hip,  Taylor's,  371 

convalescent,  374 
Splints,  Billroth,  in  treatment  of  tuber- 
culous disease  of  knee-joint,  422 
plaster,  in  treatment  of  tuberculous 

disease  of  knee-joint,  420 
in  treatment  of  infantile  talipes, 
781 
Spondylitis  deformans,  124 

diagnosis    of,    from    tubercu- 
lous disease  of  spine,  45 
pain  in,  126 


896 


IXDEX 


Spondylitis    deformans,    pathology  of. 
124 
symptoms  of.  126 
synonyms  of.  12-4 
treatment  of,  129 
tjpes  of,  127 
superficialis,  18 
traumatic.  122,  125 
sjonptoms  of.  122 
treatment  of,  122 
Spondylolisthesis.  133 

diagnosis  of.  from  tuberculous  dis- 
eases of  spine.  45 
etiology  of.  133 
treatment  of.  134 
Spontaneous   dislocation   of   hip-joint, 
401 
treatment  of.  402 
Sprain  of  ankle-joint.  465 
chronic.  46S 

treatment  of.  468 
diagnosis    of.    from    tubercu- 
losis. 461 
etiology  of,  465 
pain  in.  466 
symptoms  of,  466 
treatment  of.  466 

adhesiye-plaster       strap- 
ping in.  466 
stockinette    bandage    in, 
467 
of  wrist-joint.  487 
chi'onic,  488 

x-rays  in,  488 
pain  in,  487 
treatment  of,  487 
Sprengel's  deformity.  234 
etiology  of.  235 
treatment  of.  235 
Stiff  shoulder,  484 

Stiffness    in    tuberculous    diseases    of 
ankle-joint,  458 
of  elbow-joint,  478 
of  hip-joint.  312 
of  spine,  39 
of  vertebral  colunm.  124 
StiE's  polyarthritis.  289 
Stockinette  bandage   in   treatment    of 

sprain  of  ankle-joint,  467 
Strain  of  back,  diagnosis  of.  from  tuber- 
culous disease  of  spine.  43 
of  tendo-Achillis,  743 
Subacute  arthiitis  of  hip-joint,  401 
Subastragaloid  joint,    tuberculosis    of, 

459 
Subcutaneous  tenotomy  in  treatment 

of  neglected  talipes,  797 
Subluxation   in   acute   anterior   poUo- 
mj'elitis,  620 
of  cla^^cle,  240 

treatment  of,  241 
of  hip,  congenital.  561 
of   tibia   and   tuberculous   disease 
of  knee-joint,  415 


Subluxation  of  wrist,  500 
etiology  of.  501 
treatment  of.  501 
Subungual  exostoses  of  foot,  757 
Supernumerary  bones  of  foot.  757 
Supracotyloid     congenital    dislocation 

at  hip-joint,  538 
SwelUng  about  ankles,  472 
S^'noyial    tuberculosis    of    knee-joint. 

'429 
S^^lo^'itis,  diagnosis  of,  from  tubercu- 
lous disease  of  hip-joint,  331 
of  knee-joint.  437 
acute.  437 

treatment  of,  437 
chi'onic,  438 

diagnosis    of.    from    tubercu- 
•     losis,  419 
incidental.  439 
painless,  439 
recurrent,  438 
Syphilis  of  joints,  270 

congenital,  271 
hereditaiy,  271 
treatment  of,  274 
of  kiiee-joint,   diagnosis  of,   from 

tuberculosis,  419 
of  spine,  119 

diagnosis  of,  119 
Sypliihtic  osteochondritis,  270 


Tabetic  arthi-opathy,  295 
diagnosis  of,  298 
distribution  of.  298 
pathology  of.  296 
s^^nptoms  of,  297 
treatment  of,  298 
defoiTuity  of  spine.  133 
Table  of  age  of  incipiency  in  tubercu- 
lous disease  of  elbow- 
joint.  477 
of  shoulder-joint,  475 
of  ^Tist-joint,  482 
of  cii'ciunference  of  chest  in  child- 
hood, 242 
for  estimating  degree  of  flexion  in 
tuberculous  disease  of  liip- 
joint.  329 
of  lateral  distortion  in  tuber- 
culous disease  of  hip-joint, 
328 
of  frequency,  of  acquired  talipes, 
771 
of  congenital  talipes,  771 
of  height.  242 

in  childhood,  242 
of  length  of  bones  in  tuberculous 

diseases  of  hip-joint,  324 
of  mea^iu'ements,  327 


INDEX 


897 


Table  showing  shortening,  motion, 
number  of  sinuses  present,  and 
angle  of  greatest  extension  in  47 
cases  of  excision  in  tuberculosis 
of  hip-joint,  388 
of  strength  of  flexors  of  foot,  691 
of  weight,  242 

in  childhood,  242 
Talipes,  763 

acquired,  765,  820 

deformity     in,     development 

of,  820 
diagnosis  of,  from  congenital, 

821 
etiology  of,  820 
frequency  of,  table  of,  771 
arcuatus,  728 
calcaneovalgus,  764 
acquired,  843 

treatment  of,  844 

arthrodesis  in,  857 
tendon    implanta- 
tion in,  857 
transplantation 
in,  845 
congenital,  814 
calcaneovarus,  764 
acquired,  843 

treatment  of,  844 

arthrodesis  in,  857 
tendon  implantation 
in,  857 
transplantation 
in,  845 
congenital,  814 
calcaneus,  764 
acquired,  834 

deformity    in,     develop- 
ment of,  834 
etiology  of,  834 
symptoms  of,  834 
treatment  of,  835 

arthrodesis  in,  839 
astragalectomy  in, 

839 
backward     displace- 
ment in,  839 
Judson  brace  in,  836 
operative,  838 
silk  ligaments  in,  839 
tendon    fixation    in, 
839 
transplantation 
in,  839 
Whitman's  operation  for, 

839 
Willett's    operation    for, 
838 
congenital,  813 
cavus,  728 

congenital,  814 
congenital,  765 

etiology  of,  767 
frequency  of,  table  of,  771 
57 


Talipes  equinocavus,  congenital,  814 
equinovalgus,  764 
acquired,  831 
congenital,  814 

absence  of  fibula  and,  814 

etiology  of,  816 

statistics  of,  815 

treatment  of,  816 

equinovarus,  764 

acquired,  828 

treatment  of,  830 
anatomy  of,  772 
congenital,  772 

absence  of  tibia  and,  816 
treatment  of,  review  of, 
810 
infantile,  treatment  of,  777 
symptoms  of,  776 
treatment  of,  776 
equinus,  764 

acquired,  822 

deformity  in,    correction 

of,  825 
etiology  of,  823 
symptoms  of,  824 
treatment  of,  824 
arthrodesis  in,  828 
astragalectomy  in,  828 
backward       displace- 
ment in,   828 
operative  828 
silk  ligaments  in,  828 
tendon     displacement 
in,  828 
implantation    in, 
828 
congenital,  813 
etiology  of,  765 
hysterical,  658 

treatment  of,  658 
infantile,  treatment  of,  777 
braces  in,  781 
first-stage  of,  771 
Judson  brace  in,  781 
manipulation    in,    778 
mechanical,  778 
methodical   manual    cor- 
rection, 787 
plaster  bandage  in,   778 
rectification  of  deformity 

in,  777 
restoration    of    function, 

704 
retention  in,  by  adhesive 
plaster,  784 
by  brace,  784 
second  stage  of,  784 
splints  in,  781 
supervision  in,  787 
support  in,  784 
Taylor  brace  in,  787 
tenotomy  in,  783 
third  stage  of,  787 
neglected,  treatment  of,  788 


898 


INDEX 


Talipes,   neglected,   treatment  of,   age 
as  influencing,  788 
astragalectomy  in,  806 
division  of  tendo-Achillis 

in,  798 
forcible    manual    correc- 
tion in,  789 
importance  of  functional 

use  in,  794 
Judson  brace  in,  809 
malleotomy  in,  796 
open  incision  method  of, 

799,  803 
osteoclast  in,  802 
osteotomy  in,  806,  808 
Phelps'  operation  in,  803 
rapid    correction    of    de- 

formit}^  in,  789 
secondary  deformities  in, 

796 
simple  mechanical  recti- 
fication   of    deformity 
in  walking  cliildren  and 
in  later  years,  808 
subcutaneous     tenotomy 

in,  797 
Thomas'  method  of,  801 
Wolff's  method  of,  799 
wi'enches  in,  801 
paralytic,  834 

deformity  in,  development  of, 

834 
etiology  of,  834 
symptoms  of,  834 
treatment  of,  835 

arthi'odesis  in,  839 
astragalectomy  in,  839 
backward     displacement 

in,  839 
Judson  brace  in,  836 
operative,  838 
silk  hgaments  in,   839 
tendon   fixation    in,    839 
transplantation      in, 
839 
Whitman's  operation  for,  839 
Willett's    operation    for,    838 
plantaris,  728 
spina  bifida  and,  819 
statistics  of,  770 
valgocavus,  congenital,  814 
valgus,  764 

acquii'ed  simple,  833 
congenital,  814 
varieties  of,  764 
varus,  764 

congenital,  812 

absence  of  tibia  and,  816 
Tarsal  bones,  fractm'e  of,  469 
treatment  of,  469 
a;-rays  in,  469 
Tarsus,  tuberculosis  of,  463 
distribution  of,  464 
treatment  of,  464 


Tajdor    back   brace    in    treatment    of 
tuberculous  disease  of  spine,  85 
club-foot  brace,  785 
hip  brace  in  treatment  of  tuber- 
culous disease  of  hip-joint,  343 
on  retardation  of  growth  in  tuber- 
culous disease  of  hip-joint,  324 
convalescent   hip   splint,    374 
hip  splint,  371 
Tendo-Achillis,  division  of,  in  neglected 
tahpes,  798 
strain  of,  743 
Tendon  displacement  in  treatment  of 
acquired  talipes  equinus,  828 
fixation  in  treatment  of  acquired 
talipes   calcaneus,    839 
paralytic  talipes,  839 
implantation   in   acquired    talipes 
calcaneovarus,  857 
in  acquii'ed  talipes  calcaneo- 
valgus,  857 
calcaneovarus,  845 
in  paralytic  talipes,  839 
in  talipes  calcaneovalgus,  845 
calcaneus,  839 
equinus,  828 
Tendons,  peronei,  displacement  of,  758 

treatment  of,  758 
Tenosynovitis,  469 
treatment  of,  471 
tuberculous,  471 
of  wrist- joint,  488 
acute,  488 
chronic,  488 
Tenotomy  subcutaneous,  in  treatment 
of  neglected  talipes,  797 
in  treatment  of  infantile  talipes, 
783 
Thigh,  muscles  of,  paralysis  of,  in  acute 
anterior  poliomyelitis,  treatment  of, 
626 
Thomas'  brace  in  treatment  of  genu 
valgum,  596 
of  knock-knee,  596 
of  tuberculous  disease  of 
ankle-joint,  461 
of  knee-joint,  423 
caliper  brace  in  treatment  of  acute 

anterior   poUomj^ehtis,    634 
collar  in  treatment  of  tuberculosis 

of  spine,  93 
knock-knee    brace    in    treatment 
of  acute  anterior  pohom}'elitis, 
634 
method  of  treatment  of  neglected 

talipes,  801 
treatment  of  rigid  weak  foot,  724 
of  tuberculous  disease  of  hip- 
joint,  354 
modification  of,  359 
Thrombo-angiitis  obhterans,  745 
Tibia,   anterior  cm'vature  of,   607 

congenital     absence     of,     talipes 
equino varus   and,    816 


INDEX 


Tibia,    congenital    absence  of,    talipes 
varus  and,  816 
displacement   of,    anterior,    447 
subluration  of,  tuberculous  diseases 
of  knee-joint  and,  415 
Tibial  tubercle,  injury  of,  445 

treatment  of,  446 
Toe,  great,  arthritis  deformans  of,  748 
painful,  746 

in  older  subjects,   747 
hammer,  754 

congenital,  755 
symptoms  of,  755 
treatment  of,  755 
nail,  ingrown,  756 
pigeon,  749 
Toes,  overlapping,  756 

treatment  of,  756 
TorticoUis,  660 

acquired,  660,  665 

varieties  of,  665 
acute,  660,  665 

etiology  of,  665 
spastic,  666 
symptoms  of,  667 
treatment  of,  673 
chronic,  660 

treatment  of,  670 
congenital,  660,  661 
etiology  of,  663 
hematoma    of    sternomastoid 

and,  663 
pathology  of,  665 
deformity,  in  overcorrection  of,  671 
diagnosis  of,  668 

from  arthritis,  669 
from  tuberculous  diseases  of 
spine,  56,  668 
diphtheritic  paralysis  and,  678 
hematoma  in,  treatment  of,  670 
irregular  forms  of,  665 
mechanical,  665 
ocular,  679 
paralytic,  678 
posterior,  667 
psychical,  679 
rhachitic,  679 
simple,  665 
spasmodic,  665,  673 
etiology  of,  674 
pathology  of,  674 
prognosis  of,  674 
treatment  of,  674 
operative,  675 
statistics  of,  660 
treatment  of,  670 

subcutaneous     tenotomy    in 
670 
Traction  in  tuberculous  diseases  of  knee- 
joint,  421 
of  hip-joint,  338,  339,  341 
iransplantation  of  muscles  in  treat- 
ment of  paralysis  of  acute  anterior 
poliomyelitis,  635,  637 


Transverse  myelitis,  diagnosis  of,  from 

acute  anterior  poliomyelitis,    615 
Traumatic  coxa  vara,  574 

diagnosis  of,  from  tuberculous 
diseases  of  hip- joint,  333 
genu   recurvatum,    treatment    of, 

447 
spondylitis,  122,  125 
symptoms  of,  122 
treatment  of,  122 
Traumatisms  at  hip-joint,   399 

treatment  of,  399 
Treatment  of  abscess  in  tuberculous 
disease  of  hip-joint,  381 
of  spine,  101 
of  absence  of  patella,   450 
of  achillobursitis,  741 
of  acquired  genu  recurvatum,  446 
luxation  of  clavicle,  241 
talipes  calcaneo valgus,  844 
calcaneovarus,  844 
calcaneus,  835 
equinovarus,  830 
equinus,  824 
of  acute  anterior  poliomyelitis,  624 
infectious    arthritis    of    hip- 
joint,  400 
synovitis  of  knee-joint,  437 
of  anchylosis  of  ankle-joint,   303 
of  hip-joint,  303 
of  knee-joint,  303 
of  anterior  metatarsalgia,  738 
of  arthritis  in  infancy,  279 

of  suboccipital  region  of  spine, 
124 
of  atrophic  arthritis,  290 
of  baseball-finger,  506 
of  bilateral  disease  of  hip,  378 
of  bow-legs,  604 
of  cerebral  paralysis  of  childhood 

646 
of  Charcot's  disease  of  joints,  299 
of  chondrodystrophia,   520 
of  chronic  sprain  of  ankle-ioint, 

468 
of  club-hand,  503 
of  coccygodynia,  143 
of  congenital  club-foot,  776 
contraction  of  fingers,  505 

of  knee,  454 
dislocation  at  hip-joint,    540 
in  infancy,  549 
in  older  subjects,  553 
elevation  of  scapula,  235 
genu  recurvatum,  449 
pronation  of  forearm,   498 
of  contracted  foot,  731 
of  coxa  vara,  571 
of  cysts  of  femur,  404 
of  deformity  secondary  to  sciatica, 
loo 

of  degenerative  arthritis,  287 

of  displacement  of  peronei  tendons 

758 


900 


INDEX 


Treatment    of    displacement  of  semi- 
Ivmar  cartilage,  441 
of   Dupuytren's  contraction,  506 
of    elongation    of    ligaments    of 

patella,  453 
of  epiphyseal  fracture  of  neck  of 

femur,  576 
of  epiphysitis  at  hip- joint,  400 
of  exostoses  of  foot,  757 
of  flat  chest,  238 

of   fracture  of    metatarsal   bones, 
757 
of  neck  of  femur  in  adult  Ufa, 

577 
of  tarsal  bones,  469 
of  fragihtas  ossium,  522 
of  genu  valgum,  595 

varum,  604 
of  gluteal  bm-sitis  of  hip-joint,  403 
of  gonorrheal  arthritis,  276 

rheimaatism  of  spine,  124 
of  hallux  rigidus,  746 
valgus,  752 
varus,  749 
(of  hammer-toe,  755 
<of  hemophiha,  295 
of  hyperplasia  of  knee-joint,  444 
of  hypertrophic  arthritis,  287 
of  hysterical  tahpes,  658 
of  Uiopsoas  bursitis  of  hip-joint, 

403 
of  infantile  scorbutus,  516 
talipes,  777 

equinovarus,  777 
of  injury  of  spine,  122 

of  tibial  tubercle,  446 
of  ischemic  paralysis  and  contrac- 
tion, 508 
of  kyphosis,  231 

of  lateral  cm-vature  of  spine,  175 
of  lordosis,  233 
of  mallet-finger,  506 
of  Morton's  neuralgia,  738 
of  neglected  club-foot,  788 

tahpes,  788 
of  neurotic  joints,  659 

spine,  656 
of  obstetrical  paralysis,  491 
of  osteitis  deformans,  526,  527 
of  osteo-arthritis  of  hip-joint,  406 
of  osteochondi-itis  deformans  ju- 
venihs,  409 
dessiccans,  443 
of  osteomalacia  m  childhood,  523 
of  osteomyehtis,  acute,  280 

chi-onic,  282 
of  overlapping  toes,  756 
of  pain  in  back,  136 
of  painful  heel,  743 
of  paralysis  of  muscles  of  arm  in 
acute    anterior    poho- 
myehtis,  631 
of  liip  in  acute  anterior 
poliomyelitis,  629 


Treatment  of  paralysis  of  muscles  of 
leg    in    acute    anterior 
poliomyelitis,  625,  626 
of  thigh  in  acute  anterior 
poliomyelitis,  626 
in     tuberculous     disease     of 
spine,  110 
of  paralytic  scoliosis  in  acute  ante- 
rior poliomyeUtis,  631 
tahpes,  835 
of   periarthi'itis   of   shoulder,    486 
of  pigeon  chest,  239 
of  plantar  neuralgia,  744 
of  prepatellar  bursitis,  444 
of  pretibial  binsitis,  445 
of  proUferating  arthritis,  287 
of    pseudohypertrophic    muscular 

paralysis,  653 
of  recm-rent  dislocation  of  shoulder, 

497 
of  rhachitic  spine,  131 
of  rhachitis,  515 
of  rigid  weak  foot,  718 
of  rudimentary  patella,  450 
of  sacro-ihac  disease,  140 
of  simple  fracture  of  neck  of  femur, 

576 
of    sinuses  in  tuberculous   disease 

of  liip-joint,  383 
of  shpping  patella,  451 
of  snapping  knee,  454 
of  spina  ventosa,  484 
of  spondyUtis  deformans,  129 
of  spondylolisthesis,  134 
of  spontaneous  dislocation  of  hip- 
joint,  402 
of  sprain  of  ankle-joint,  466 

of  \\Tist-joint,  487 
of  Sprengel's  deformity,  235 
of  subluxation  of  clavicle,  241 

of  wTfist,  501 
of  syphihs  of  joints,  274 
of  tabetic  arthropathy,  298 
of  talipes  equinovarus,  776 
of  tenosynovitis,  471 
of  torticolhs,  670 
of  traumatic  genu  recurvatum,  447 

spondylitis,  122 
of  traumatisms  at  hip-joint,  399 
of  trigger-finger,  506 
of  tuberculous   disease   of   ankle- 
jomt,  461 
of  bones,  262 
of  elbow-joint,  479 
of  hip-joint,  336 
of  joints,  262 
of  knee-joint,  420 
of  shoulder-joint,  475 
of  spine,  61 
of  tarsus,  464 
of  wiist- joint,  482 
of  "typhoid  spine,"  123 
of  weak  foot,  710 
of  webbed  fingers,  505 


INDEX 


901 


rigger-finger,  505 

etiology  of,  505 
synonyms  of,  505 
treatment  of,  506 
Trunk,  deformities  of.  in  acute  ante- 
rior poliomyelitis,  620 
Tubercle,  tibial,  injury  of,  445 

treatment  of,  446 
Tuberculous  disease  of  ankle-joint,  455 
age  in,  457 
deformity  in,  458 

reduction  of,  461 
diagnosis  of,  459 

from  arthritis  deformans 

461 
from  flat-foot,  461 
from  infectious  arthritis, 

461 
from  rheumatism,  461 
from  sprains,  461 
etiology  of,  456 
hmp  in,  458 
pathology  of,  455 
prognosis  of,  463 
situation  of,  456 
stiffness  in,  458 
symptoms  of,  457 
treatment  of,  461 
operative,  462 
Thomas'  brace  in,  461 
of  astragal onavicular  joint  459 
of  bones,  249  ' 

abscess  in,  255 
age  in,  253 
diagnosis  of,  262 

x-Y&ys  in,  262 
distribution  of,  252 
dry  caries  in,  259 
etiology  of,  249 
latent,  249 

mode  of  infection  in,  249 
pathology  of,  254 
predisposition  to,  249,  251 
prognosis  of,  260 
repair  in,  259 
septic  infection  in,  259 
sex  in,  253 
side  affected  in,  253 
treatment  of,  262 
Beck's  265 
drugs  in,  264 
iodoform   filling  in,    265 
mechanical,  264 
operative,  264 
sunlight  in,  262 
f-rays  in,  266 
01  elbow-jomt,  477 
age  in,  477 
atrophy  in,  478 
deformity  in,  478 

reduction  of,  480 
occurrence  of,  477 
pain  in,  478 
pathology  of,  477 


Tuberculous   diseass    of    elbow-joint, 
prognosis  of,  480 
sensitiveness  in,  478 
stiffness  in,  478 
swelling  in,  478 
symptoms  of,  478 
treatment  of,  479 
excision  in,  480 
operative,  480 
of  hip-joint,  305 
abscess  in,  379 

significance  of,  381 
statistics  of,  379 
treatment  of,  381 
actual  lengthening  in,  325 

shortening  in,  322 
in  adults,  379 
age  in,  310 
apparent  lengthening  in,  312 

shortening  in,  314 
Ashley's  details  of  1000  cases 

of,  335 
atrophy  in,  319 
causing  equinus,  398 

genu  recurvatum,  398 
knock-knee,  398 
lateral  curvature,  398 
laxity  of  ligaments,  398 
lordosis,  398 
changes  in  contour  of  hip  in, 

319 
debihty  in,  325 
deformity   in,    correction    of. 

389 
diagnosis  of,  330 

from  anterior  poliomye- 
litis, 331 
from  arthritis  deformans'- 

of  hip,  332 
from   congenital   disloca- 
tion of  hip,  333 
from  coxa  vara,  332 
from  disease  of  bursse,  332 
from  epiphyseal  fracture, 
.    333 

from  epiphysitis,  331 
from  extra-articular    dis- 
ease, 331 
from  fracture  of  neck  of 
femur    in      childhood, 
333 
from  gonorrheal  arthritis, 

331 
from  growing  pains,  330 
from  hysterical  joint,  333 
from  infectious  arthritis, 

331 
from  local  injury,  330 

irritation,  330 
from  pelvic  disease,  332 
from  Perthes'  disease,  331 
from  proliferative  polyar- 
thritis, 332 
from  rheumatism,  331 


902 


INDEX 


Tuberculous  disease  of  hip-joint,  diag- 
nosis  of,    from    sacro- 
iliac disease,  332 
from  scur\'>',  331 
from  s^-novitis,  331 
from  traumatic  coxa  vara, 

333 
from  tuberculoiis  disease 

of  spine,  332 
.T-rays  in,  333 
distortion  of  limb  in,  312 
estimation  of,  328 
of  atrophy  in,  330 
Kingslev's     method, 
329 
etiology  of,  309 
examinatioti    in,    method    oi, 
325 
physical,  326 
fever  in,  325 
frequency  of,  309 
history  in,  325 
in  infancy,  379 
Konig's  statistics  of,  315 
limp  in,  311 
local  signs  of,  330 
measm-ements  in,  327 
mortality  in,  392 
muscular  spasm  in,  312 
night  cry  in,  311 
pain  in,  310 
pathology  of,  305 
physical  signs  in,  311 
prognosis  of,  392 
recorcUng  case  of,  333 
reduction    of    deformity    in, 
by  traction  brace,  344 
by  weight  and  pidley,344 
retardation  of  growth  in,  323 
rallinger  on,   323 
Taylor  on,  324 
sex  in,  310 
side  affected  in,  310 
sinuses  in.  treatment  of,  383 
stiffness  in,  312 
sjnaptoms  of,  310 

general,  325 
treatment  of,  336 

amputation  in,  388 
Bradford  brace  in,  343 
dm-ing  stage  of  recovery, 

373 
fimctional  results  of,  394 
high  shoe  in,  341 
Judson  brace  in,  342 
lateral  traction  in,  _347 
Lorenz  spica  in,  365 
mechanical,  337  ^ 
re\'iew  of,  370 
sphnting,  3_37 
stilting,  337 
traction,  337 
operative,  excision,  384 
perineal  bands  in,  341 


Tuberculous  disease  of  hip-jomt,  tret' 
ment    of,    plaster   sup- 
ports in,  359 
Tavlor  hip  brace  in,  343 
Thomas',  354 

modification  of,  359 
traction  hip  sphnt  in,  338 
plasters  in,  339 
of  joints,  249 

abscess  in,  255 
age  in,  253 

arborescent  s\-no\'ial,  258 
chagnosis  of,  262 

.T-rays  in,  262 
distribution  of,  252 
dry  caries  in,  259 
etiologv  of,  249 
latent,  249 
I  mode  of  infection  in,  249 

pathology  of,  254 
perforation  in,  256 
predisposition  to,  249,  251 
prognosis  of,  260 
repair  in,  259 
rice  bodies  in,  258 
septic  infection  in,  259 
sex  in,  253 
side  affected  in,  253 
treatment  of,  262 

active  congestion  in,  268 
Bier's  h^i^eremia  in,  266 
Calot's  fluids  in,  265 
drugs  in,  264 
iodoform  in,  265 
mechanical,  264 
operative,  264 
passive  congestion  in,  267 
simUght  in,  262 
.r-rays  in,  266 
of  knee-joint,  410 
abscess  in,  428 
actual  lengthening  m,  418 

shortening  in,  418 
age  in,  413 

causes  of  death  in,  435 
complications  of,  428 
deformities  in,  secondary,  41o 
deformity  in,  reduction  of,  420 
•    diagnosis  of.  418 

from  arthritis  deformans, 

419 
from    Charcot's   disease, 

419 
from  hemathrosis,  419 
from  hysterical  joint,  419 
from  infectious  arthi-itis, 

419 
from  injury  of  knee,  418 
from  rheumatism,  419 
from  sarcoma,  419 
from  s}mo\'itis,  419 
from  sypliihs,  419 
cUstortions  in,  414 
etiology  of,  413 


INDEX 


903 


^Gerculous  diseaseof  knee-joint,  extra- 
-     •  articular  disease  and,  428 

knock-knee  and,  416 
limitation  of  motion  in,   414 
limp  in,  414 
mortality  in,  434 
occiurence  of,  413 
■   pain  in,  414 
pathology  of,  410 
prognosis  of,  433 
rotation  of  tibia  upon  femur 

and,  415 
subluxation  of  tibia  and,  415 
sjTnptoms  of,  413 
synonyms  of,  410 
synovial,  429 
treatment  of,  420 
accessory,  427 
amputation  in,  432 
arthrectomy  in,  430 
Bier's,  427 

Billroth  splint  in,  422 
caliper  brace  in,  426 
during  convalescence,  428 
excision  in,  431 

results  of,  432 
forcible  correction  by  re- 
verse leverage,  421 
functional  results  of,  434 
ichthyol  ointment  in,  427 
mechanical,  423 
operative,  430 

for  rehef  of  final  de- 
fofmity,  432 
passive  congestion  in,  427 
plaster  sphnt  in,  420 
Thomas  brace  in,  423 
traction  in,  421 
x-rays  in,  427 
of  shoulder-joint,  473 
age  in,  475 
atrophy  in,  475 
paiii  in,  475 
pathology  of,  473 
prognosis  of,  477 
restriction  of  motion  in,  475 
sensitiveness  in,  475 
symptoms  of,  475 
treatment  of,  475 
of  spine,  17 

abscess  in,  29,  98 

course    and    peculiarities 
of,  in  different  regions, 
100 
treatment  of,  101 
age  at  onset  of,  22 
attitude  in,  change  of,  27 
awkwardness  in,  27 
case  record  in,  60 
compUcations  of,  98 
contour  of  spine  in,  29 
change  of,  28 
deformity  in,  17,  28 
bone,  28 


Tuberculous  disease  of  spine,  deformity 
in,  compensatory,  28 
later  effects  of,  117 
muscular,  28 
secondary,  118 
diagnosis    of,    from    cerebro- 
spinal meningitis,  60 
from    congenital  disloca- 
tion of  hip-joint,  539 
from  diphtheritic  paraly- 
sis, 60 
from      primary      spastic 

spinal  paraplegia,  60 

from  pseudohypertrophic 

muscular  dystrophy,  59 

from  spastic  paralysis,  60 

from  tuberculous  disease 

of  hip-joint,  332 
general,  59 

Roentgen-ray        photog- 
raphy in,  60 
etiology  of,  21 

examination  in,   regional,   37 
flexibihty  of  spine  in,  29 
frequency  of,  21 
history  in,  34 

impairment  of  function  in,  27 
loss  of  mobility  in,  27 
in  lower  cervical  region,  55 
region,  37 

attitude  in,  37 
diagnosis  of,  43 

from  acute  rhachitis, 

47 
from  appendicitis,  46 
from    bilateral    con- 
genital dislocation 
of  hip,  45 
from  hernia,  47 
from  hip  disease,  45 
from  lumbago,  43 
from  muscular  dys- 
trophies, 45 
from  pelvic  abscess, 

46 
from      perineprhitic 

abscess,  46 
from  sacro-iliac  dis- 
ease, 45 
from  sciatica,  44 
from  scurvy,  47 
from  spondylitis  de- 
formans, 45 
from  spondyloKsthe- 

sis,  45 
from  strain  of  back, 
43 
lateral    inclination    of 

body  in,  38 
lordosis  in,  37 
pain  in,  38,  39 
peculiarities  of,  in  in- 
fancy, 47 
pelvic  abscess  in,  43 


90-4 


INDEX 


Tuberculous  disease  of  spine  in  lower 
region,    psoas    con- 
traction in,  38 
stiffness  in,  39 
stooping  in,  40 
symptoms  of,  48 
treatment  of,  96 
weakness  in,  39 
in  middle  and  upper  dorsal 

region,  treatment  of,   97 
"  night  cr3'"  in,  27 
in  occipito-axoid  region,  treat- 
ment of,  98 
pain  in,  27 
paralysis  in,  29,  105 
dm-ation  of,  107 
frequency  of,  106 
laminectomy  in.  111 
liability  to,   in   different 

regions,  106 
local,  112 
prognosis  of,  109 
sjTnptoms  of,  107 
time  of  onset  of,  107 
treatment  of,  110 
pathology  of,  18 
physical  signs  of,  35 
prognosis  of,  25 
rational  signs  of,  34 
recurrence  of,  117 
sex  in,  22 
situation  of,  23 
stiffness  in,  27 
sjTnptoms  of,  26 

compHcating,  29 
general,  29 
secondary,  29 
sjTionjTn  of,  17 
in  thoracic  region,  48 
abscess  in,  51 
attitudes  in,  48 
cough  in,  50 
deviation  of  spine  in,  51 
diagnosis  of,  51 

from  empyema,  52 
from  plemisy,  52 
from  pneimionia,  52 
from     rotarj^-lateral  i 
curvatiu-e,  52  j 

from  "round  shoul- j 
ders,"51_  i 

muscular  spasm  in,  50       i 
pain  in,  50  j 

pigeon  chest  in,  49 
resphation  in,  50 
sjTnptoms    of,    summary 
of,  53 
treatment  of,  61 

ambulatory  supports  in, 

70 
Bradford   bed  frame   in, 

63 
Calot  jacket   in,   76,  80, 
38  ■ 


Tuberculous  disease  of  spine,.  vaiLT'  of 
of,   comparison  of  i  '^" 
two  fomis  of  ambula- 
tor}' support  in,  92 
convex    stretcher    frp" 

in,  63 
corsets     in,    otl 
plaster-of-  , 
plaster,  84 
duration  of,  116 
horizontal  fixation  in,  6 
jury-mast  in,  74 
Lorenz  apparatus  in,  63 
mechanical,  principles  of, 

61 
operative,  112 
Phelps  bed  in,  63 
plaster  jacket  in,    70 
by    recumbency,    indica- 
tions for,  95 
Taylor  back  brace  in,  85 
Thomas   coUar   in,    93 
in  upper  dorsal  and  middle 
cer\'ical  region,   treat- 
ment of,  98 
region,  53 

attitude  in,  53 
diagnosis  of,  56 
from  abscess,  59 
from  arthritis,  59 
from    cer^■ical    opis- 
thotonos, 58 
from  injury,  58 
from  torticollis,  56 
pain  in,  53 
stiff  neck  in,  53 
sjinptoms  of,  53 
summary  of,  59 
weak  foot  and,  118 
weakness  in,  27 
subastragaloid  joint,  459 
of  tarsus,  463 

distribution  of,  464 
treatment  of,  464 
of  wi'ist-joint,  481 
age  in,  482 
atrophy  in,  482 
limitation  of  motion  in,  482 
pain  in,  482 
prognosis  of,  484 
sensitiveness  in,  4S2 
sweUing  in,  482 
SAinptoms  of,  482 
treatment  of,  482 
Tuberculous  ai-thritis,  279 
rheumatism,  294 
tenosj'no"\"itis,  471 
Tumor  albus,  410 
Tumors  of  bone,  304 

of  spine,  119 
Tj'phoid  fever,  arthiitis  and,  277 
spine,  123 

diagnosis  of,  123 
treatment  of,  123 


L 


INDEX 


905 


placement    of,    congenital, 

angenital  dislocation  at  hip- 

535 
kra,  567 
/algum,  592 
|knee,  592 

femity,  deformities  of,  489 
I       in   acute   anterior   polio- 
myelitis, 620 


Valgus   deformities,    congenital   genu 

recurvatim  and,  448 
Varus    defcrmities,     congenital     genu 

recurvatuia  and,  448 
Vasomotor    rophic    neuroses  of  foot, 

744 
Vertebrae,  deficiency  of,  236 

malformaiion  of,  236 
Vertebral  colunn,  stiffness  of,  124 
Volkmann  seat  in  lateral  curvature  of 

spine,  226 


W 


Waddle  in  congmital  dislocation  at 

hip-joint,  536 
Warts,  painful,  740 
Weak  foot,  693 

in  childhool,  706 

deformity    of    legs    and, 

708^ 
general    weakness     and, 

708 
irregula?  forms  of,  708 
symptoms   of,    in-toeing, 
707 
out-toeing,    707 
outgrown        joints, 

707 
weak   t'.nkles,    707 
diagnosis <«)f,  700 

attitudes  in,  700 
bearing  surface  of,  702 
contour  in,  701 
distribution     of     weight 

and  strain  in,  701 
range  of  motion  of,  702 
etiology  of,  696 
limitation  of  motion  in,  704 
muscular  spasm  in,  704 
pathology  of,  698 
review  of,  709 
rigid,  718 

treatment  of,  718 
adjuncts  in,  724 
manipulatioti        in, 
721 


Weak  foot,  rigid,  treatment  of,  over- 
correction in,  719 
plaster    strapping, 

724 
_  Thomas',  724 
varieties  of,  723 
statistics  of,  697 
symptoms  of,  698 
treatment  of,  710 
attitudes  in,  711 
brace  in,  715 

construction  of,  713 
exercise  in,  711 
operative,  726 
plaster  cast  in,  713 
shoe  in,  710 

raising  inner  border 
of,  711 
support  in,  712 
types  of,  705 

persistent  abduction,  705 
pes  planus,  705 
varieties  of,  704 
Weakness  of  anterior  metatarsal  arch, 
732 
diagnosis  of,  from  acute  anterior 

poUomyehtis,  616 
in   tuberculous    disease  of    spine, 
39 
Webbed  fingers,  505 

etiology  of,  505 
treatment  of,  505 
Webb's  treatment  of  ingrown  toe-nail, 

756 
Weight  in  childhood,  table  of,  242 

of    muscular    substance    of    long 
muscles  of   lower  extremity  of 
adult,  846 
table  of,  242 
White  swelling,  410 
Whitman's  method  of  correcting  flexion 
deformity   at   knee  by  reverse 
leverage,  442 
operation  in  acquired  talipes  cal- 
caneus, 839 
for  paralytic  talipes,  839 
WOlett's  operation  for  acquired  talipes 
calcaneus,  838 
paralytic  tahpes,  838 
Wolff's  law  of  functional  pathogenesis 
of  deformity,  242 
treatment  of  genu  valgum,  601 
of  knock-knee,  601 
of  neglected  tahpes,  799 
Wrenches  in   treatment   of   neglected 

tahpes,  801 
Wrist,      congenital      deformities     at, 
501 
subluxation  of,  500 
etiology  of,  501 
treatment  of,  501 
Wrist-joint,  sprain  of,  487 
chronic,  488 

a;-rays  in,  488 


906 


IXDEX 


Wrist-joint,  sprain  of,  pain  in,  4S7 

treatment  of,  4S7 
tenos^^lo^'itis  of,  4SS 

a-cute.  488 

chronic,  488 
tuberculous  disease  of,  481 

age  in,  482 

atrophy  in,  482 

limitation  of  motion  in,  482 

pain  in,  4S2 

prognosis  of,  4S4 

sensitiveness  in,  482 

swelling  in,  482 

sjTiiptoms  of.  482 

treatment  of.  4S2 
Wrj'-neck,  660.    See  Torticollis. 


X-RAYS  in  diagnosis  of  ostiti 
of  tuberculous  dise 
262  _  I 

of  liip-joint,  A 
of  joints,  262  { 
in  dj'schondroplasia,  5:'i 
in  fracture  of  tarsal  boi\ 
in  osteochonchitis  dessicj 
in  sprain  of  -nTist-joLnli 

488 
in  treatment  of  tuberculo  / 
of  bones,  266  / 
of  joints   "'^^     , 


Date  Due 


\„ 

! 

.^  il  i  «  i    ._.   ^ 

..^  v.. 

my  2  2 

'94^ 

1     1 

^ 

1     1 

N>~^  \i^\ 


l\\s 


V.Vl*-w4MX_ 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  731  W59  1917  C.1 

A  treatise  on  orthopedic  surqerv 


2002311640 


7di  //^id^^i^^r'C^^''^^  ']r\ 

J  Diy  Royal  Wilitajajv 


383  LEXINGTON    AVENUE 


